Are adrenal injuries predictive of adrenal insufficiency in patients sustaining blunt trauma?

Adrenal insufficiency (AI) is an uncommon life-threatening development in trauma patients. The aim of this study was to determine if adrenal injury sustained during blunt trauma is associated with an increased risk of AI. A single-institution retrospective cohort review was performed over a 3-year period on all patients with blunt trauma requiring intensive care admission and mechanical ventilation for longer than 24 hours. Adrenal injuries were identified on admission CT scan. All patients with AI were identified as noted by practice management guidelines. Patients were stratified by Injury Severity Score (ISS) as less than 16, 16 to 25, and greater than 25 and relative risks were calculated. Multiple logistic regression was performed using age, race, sex, Glasgow Coma Scale, ISS, length of hospitalization, and adrenal injury as covariates with AI as the outcome of interest. A secondary analysis was then performed with adrenal injury classified as bilateral versus unilateral or no adrenal injury and relative risks were calculated for ISS strata. A total of 2072 patients were identified with 71 developing AI. Adrenal injuries were noted in 113 patients with eight subsequently developing AI. Multiple logistic regression model (P < 0.01) showed that age (P < 0.01) and increasing ISS (P = 0.02) were predictive of AI. Adrenal injury was not an independent predictor of AI (P = 0.12). After controlling for age and ISS, adrenal injury was not an independent predictor of the development of AI. Adrenal insufficiency should be considered with increasing injury severity and age in the intensive care setting after blunt trauma.     

Linfangioma quístico de origen adrenal

Imagen 1 – TAC: Corte transversal a nivel de los riñones, donde se observa el desplazamiento del riñón derecho por una imagen quística de contenido homogéneo.Imagen 2 – RNM: Corte transversal y longitudinal. Imagen bien delimitada de ontenido líquido.

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Are the clinically important adrenal cysts hamartomas?

An adrenal cyst in a 36-year-old apparently healthy woman was diagnosed as a hamartoma with haemangiomatous structures and a large cyst, probably secondary to haemorrhage within the lesion. After reviewing the histological records of all the previously published cases of similar "haemorrhagic" non-inflammatory adrenal cysts, the aetiology of which has been considered unclear, we conclude that they too were probably hamartomas. We therefore propose that this type of adrenal cyst, the only of clinical importance, is aetiologically a hamartoma. These tumours often show super-imposed degenerative post-haemorrhagic changes.     

Do we still have glucocorticoid-induced adrenal insufficiency?

Adrenal insufficiency (AI) induced by glucocorticoids was first described more than 50 years ago in patients undergoing surgical stress. Although considered the most frequent cause of AI, the true incidence of this complication of glucocorticoid treatment remains unknown. No factors are known to predict AI after glucocorticoid treatment. In particular, neither the dose nor the duration of treatment seems predictive. The minimum dose of cortisol necessary for the body to cope with medical or surgical stress is unknown. The adrenocorticotropin test is often used during corticosteroid withdrawal because it is well correlated with adrenal response to surgical stress, but not with clinical events. Studies over the past 15 years have shown that the perioperative risk of AI has been overestimated and that hydrocortisone doses should be decreased. A prospective study of patients after steroid withdrawal is the only means of assessing the true incidence of this complication to propose a rational strategy to prevent it.     

What adrenal incidentalomas are to be operated?

AIM OF THE STUDY: The goal of this retrospective study was to recognize the incidence of adrenal tumors called incidentalomas, that are in fact symptomatic or hormone secreting tumors, to assess if the diagnostic criteria proposed in the literature are reliable for adrenal tumors found incidentally. PATIENTS AND METHOD: The records concerned 147 patients operated between April 1981 and December 2000 for an adrenal mass measuring 3 cm in diameter and larger on CT scan. Clinical and laboratory findings as well as hormone levels and imaging examinations (CT Scan, IRM, scintigraphy) were correlated with operative findings and results of histologic examinations. One hundred and three patients were operated by a traditional approach and forty four by videoendoscopic techniques. RESULTS: In 41 patients (28%), the tumors had to be classified as false incidentalomas (group 1) postoperatively. In 106 patients (72%), the nature of tumor was non definite. In this group 2, there were ten malignant tumors, two pheochromocytomas and 94 benign lesions. Age of patient, size of tumor, increase in size over time and radiological appearance represent criteria that are not reliable to separate malignant from benign tumors. CONCLUSIONS: Tumors of indeterminated and non specific nature only should be classified as incidentalomas. Imaging techniques as well as other criteria of malignancy cannot be relied upon to separate benign from malignant tumors. The risk even small of cancer or pheochromocytoma leads us to recommend excision of tumors > or = 3 cm in radiological diameter. The videoendoscopic approach is a good alternative to open operation in centers with this special expertise.     

Hypothalamic–pituitary–adrenal function: anaesthetic implications

Surgery, trauma and critical illness evoke a series of hormonal and metabolic changes commonly referred to as the stress response. Activation of the hypothalamic–pituitary–adrenal axis results in increased secretion of hormones such as cortisol. Anaesthesia can suppress adrenocortical secretion either by an effect at the hypothalamus, for example by a decrease in neural input with regional anaesthesia, or by a direct effect on the adrenal cortex, for example by etomidate. For patients undergoing routine surgery an increase in cortisol secretion is unnecessary, uneventful recovery occurs in the presence of circulating cortisol concentrations within the normal range. Patients often present for surgery taking corticosteroids for a variety of medical conditions, but excessive supplementation with hydrocortisone is unnecessary, and can cause side effects. The use of steroids in critically ill patients remains contentious. Furthermore, the immune system and neuroendocrine system are closely related and the metabolic response to surgery involves both hormonal and inflammatory processes. Attempts have also been made to obtund the perioperative inflammatory response.     

Incidence of adrenal involvement and assessing adrenal function in patients with renal cell carcinoma: Is ipsilateral adrenalectomy indispensable during radical nephrectomy?

OBJECTIVE: To determine the value of ipsilateral adrenalectomy with radical nephrectomy, by investigating the clinical aspects of adrenal involvement and adrenocortical function in patients with renal cell carcinoma (RCC). PATIENTS AND METHODS: The demographic, clinical and pathological data of adrenal involvement were reviewed in 247 patients with RCC. To evaluate adrenocortical function, 14 patients (adrenalectomy in eight, adrenal-sparing in six) had a rapid adrenocorticotropic hormone (ACTH) stimulation test before and 2 weeks after surgery. RESULTS: There was adrenal involvement with RCC in seven of the 247 (2.8%) patients (a solitary adrenal metastatic tumour in four and direct extension into the adrenal gland in three). All adrenal involvement was detectable on abdominal computed tomography before surgery, and these patients had a large primary renal tumour of > pT2 and/or distant metastasis. Plasma cortisol levels declined significantly more in response to the rapid ACTH stimulation test in those treated by adrenalectomy than in those with spared adrenal glands at 2 weeks after surgery (P < 0.05), while there was no significant difference between the groups before surgery. CONCLUSIONS: These results suggest that unconditional ipsilateral adrenalectomy with radical nephrectomy for RCC should be avoidable, and thus preserve the reserve of adrenocortical function, as preoperative imaging, especially thin-slice multidetector helical computed tomography, can detect adrenal involvement with RCC in most cases. Unilateral adrenalectomy might cause an irreversible impairment of the reserve of adrenocortical function.     

Coincidental adrenal ganglioneuroma – a case presenting with enuresis nocturna

A 9-year-old boy presenting with primary enuresis nocturna was discovered to harbour a large left adrenal mass which produced no hormonal abnormalities. He was undergone an exploration and the mass was removed completely. It was found to be an adrenal ganglioneuroma weighing 240 g. Though no cause-and-effect relationship is established, the case no long suffered from enuresis soon after surgery and free of recurrence after 5 years.     

Laparoscopic appreciation of the adrenal artery: fact or fiction?

BACKGROUND: It is well accepted that identification and control of the adrenal vein is a critical step in laparoscopic adrenalectomy. The surgical and anatomic literature propagates the notion of a dominant or multiple dominant adrenal arteries that should likewise be controlled during surgical extirpation. MATERIALS AND METHODS: We assessed the frequency of adrenal-artery identification and the need for formal ligation in an extensive series of laparoscopic adrenalectomies. RESULTS: In our experience, even using a magnified laparoscopic view, we found it possible to identify and necessary to formally ligate an adrenal artery in only 3 of 265 cases (1.1%). Further, in this series, only the inferior adrenal artery was ever seen definitively to require formal clip ligation, while a discrete middle or superior adrenal artery was almost never seen, and the vasculature in these areas could be controlled with electrocautery or ultrasonic energy alone during routine dissection. CONCLUSIONS: The need to search for and ligate the arterial supply during laparoscopic adrenalectomy is not as clinically significant as once thought, and formal control appears unnecessary unless the vessels are serendipitously encountered during the routine dissection.     

Relative adrenal insufficiency in etomidate-naïve patients with septic shock

A recent study reported that 77% of patients with septic shock had relative adrenal insufficiency. However, all patients were mechanically ventilated and received high-dose inotropes. In addition, at least 24% had prior exposure to etomidate, a drug known to suppress adrenal function. We studied the incidence of relative adrenal insufficiency in etomidate-na?ve patients with septic shock by analysing the adrenal response to high-dose short synacthen test in 113 consecutive patients from three university-affiliated intensive care units in Australia. Patients were allocated to three groups according to severity of illness and inclusion criteria of the trial of low dose hydrocortisone supplementation using information from patient records. Of the 113 patients, 98 had septic shock (Group A). The incidence of relative adrenal insufficiency in this subpopulation was 24.5%. Eighty-one per cent of patients with septic shock were mechanically ventilated (Group B). In this group, the incidence of relative adrenal insufficiency was 27.8%. Only 38 of the 98 patients with septic shock (39%) fulfilled inclusion criteria for the steroid supplementation trial (Group C). In this group, the incidence of relative adrenal insufficiency was only 34.2%. In all groups its presence was associated with a higher mortality. We conclude that the incidence of relative adrenal insufficiency in etomidate-naive septic shock patients was lower than observed in the steroid supplementation trial. Further, in those who fulfilled inclusion criteria for the trial, the incidence of relative adrenal insufficiency was half that reported by the trial. Our observations raise concerns about the generalizability of the findings of the above trial to etomidate-na?ve patients.     

When should incidentalomas of the adrenal gland be surgically treated?

Between January 1981 and December 1988 a total of 95 patients underwent surgery for adrenal tumors. In 24 cases (25.3%) a so-called "incidentaloma" was found. While seven of these tumors showed hormonal activity, in seventeen patients the tumor was hormonal inactive. The size of the tumors ranged between 2 and 11 cm. Histologically all tumors were found to be benign neoplasms. Because of the lack of lethality and minimal morbidity we indicate surgery on incidentaloma of the adrenal gland for the following reasons: tumors with hormone activity, tumor size larger than 3 cm, suspecting malignoma or metastasis and finally in proven enlargement of small tumors. Only in adrenal tumors smaller than 3 cm we suggest a follow-up by ultrasound or computed tomography.     

Is surgery necessary for incidentally discovered adrenal masses in children?

Background

There are no guidelines that exist to direct the management of incidental adrenal masses (IAM) in children. The aim of this study was to determine if there is a subset of IAMs that could be safely observed.

Methods

A retrospective analysis was conducted of all adrenal masses that were either resected or biopsied between 1990 and 2002 (n = 91) at the Hospital for Sick Children, Toronto. IAM was defined as a solitary adrenal mass discovered by either physical examination (n = 6; 23.1%) or diagnostic imaging for other indications (n = 20; 76.9%), without metastases or biochemical activity.

Results

Twenty-six (28.6%) IAMs were detected (mean age, 4.6 years [range, antenatal to 17 years]; 11 boys, 15 girls). Pathologic diagnoses included neuroblastoma (n = 7), ganglioneuroma (n = 6), adrenocortical adenoma (n = 4), adrenal cyst/pseudocyst (n = 3), adrenal hemorrhage (n = 3), ganglioneuroblastoma (n = 1), nodular cortical hyperplasia (n = 1), and teratoma (n = 1). Eight masses were malignant (30.8%). Two of the 5 masses discovered on antenatal ultrasound scan were neuroblastoma. In comparing the benign with malignant lesions, there was no significant difference in mean size (4.8 cm v 4.3 cm; P = .57), radiologic characteristics, or mode of presentation. Benign lesions occurred more frequently in older children (mean age, 6.5 years v 1.3 years; P = .03).

Conclusions

Clear guidelines cannot be established to predict benign IAM in children. Given the high proportion of malignant lesions, we recommend that all pediatric IAMs should be resected.     

Chemotherapy for advanced adrenal cancer: improvement from a molecular approach?

Advanced adrenal carcinoma remains a significant therapeutic challenge, with conventional approaches to systemic therapy having failed to achieve sustained objective remissions or major survival benefit in most instances. Several systemic therapies, including mitotane, suramin and gossypol, as well as cytotoxic agents, such as cisplatin and etoposide, have produced responses of ≈15-30%, with median survival figures of ≈6-15 months, depending on case selection bias, with only <10% 5-year survival rates. Recent preclinical and pathological studies have indicated a range of potential targets for drugs, including WNT/beta-catenin, epidermal growth factor receptor, RAF and k-RAS; similar applications in melanoma and renal carcinoma have achieved significant gains, and these targets are worthy of further, structured investigation. Advanced adrenal carcinoma constitutes an orphan disease, with a high mortality rate, and merits investment in clinical trials.     

Feminizing genitoplasty for congenital adrenal hyperplasia: what happens at puberty?

PURPOSE: We document the postpubertal outcome of feminizing genitoplasty. MATERIALS AND METHODS: A total of 14 girls, mean age 13.1 years, with congenital adrenal hyperplasia were assessed under anesthesia by a pediatric urologist, plastic/reconstructive surgeon and gynecologist. Of these patients 13 had previously undergone feminizing genitoplasty in early childhood at 4 different specialist centers in the United Kingdom. RESULTS: The outcome of clitoral surgery was unsatisfactory (clitoral atrophy or prominent glans) in 6 girls, including 3 whose genitoplasty had been performed by 3 different specialist pediatric urologists. Additional vaginal surgery was necessary for normal comfortable intercourse in 13 patients. Fibrosis and scarring were most evident in those who had undergone aggressive attempts at vaginal reconstruction in infancy. CONCLUSIONS: These disappointing results, even in the hands of specialists, highlight the importance of late followup and challenge the prevailing assumption that total correction can be achieved with a single stage operation in infancy. Although simple exteriorization of a low vagina can reasonably be combined with cosmetic correction of virilized external genitalia in infancy, we now believe that in some cases it may be best to defer definitive reconstruction of the intermediate or high vagina until after puberty. The psychological issues surrounding sexuality in these patients are inadequately researched and poorly understood.