Cystic adrenal lesions - analysis of indications and results of treatment

Cysts are a rare pathology of adrenal glands. As the development of new diagnostic techniques takes place, the occurrence of adrenal cystic lesions has been rapidly increasing. The majority of them are solid adrenal lesions, but localized fluid collections are also more frequently diagnosed. In case of solid adrenal lesions, there are straight indications for surgery, but on the other hand there are no clear guidelines and recommendations in case of adrenal cysts. The aim of the study was to analyze surgical methods and evaluate treatment effects in patients who were qualified for laparoscopic adrenalectomy due to adrenal cystic lesions. METARIAL AND METHODS: Identical criteria were used to qualify patients with solid and cystic lesions of the adrenal gland for surgery. Out of the whole number of 345 patients who underwent laparoscopic surgery for adrenal tumors, 28 had adrenal cysts. 16 of them (57%) were women and 12 (43%) men. The average age of the studied group was 46.4 years (25-62 years). The average cyst diameter in CT was 5.32 cm (1.1-10 cm). Most of the lesions were hormonally inactive (22 patients), but in 6 cases increased level of adrenal hormones was observed. RESULTS: Pathological analysis revealed 4 (14%) pheochromocytomas and 2 (7%) dermoid cysts. In case of 22 (79%) patients, the postoperative material was profiled by pathologists as insignificant according to potential neoplasmatic transformation risk: 5 (17.5%) - endothelial vascular cysts, 3 (11%) endothelial lymphatic cysts, 7 (25.5%) pseudocysts, 3 (11%) simple cysts, 2 (7%) bronchogenic cysts, 1 (3.5%) - cortical adenoma and 1 (3.5%) cyst was of myelolipoma type. CONCLUSIONS: Based on the performed research and previous experience in treating patients with adrenal lesions we can conclude that application of the same evaluating algorithm for both cystic and solid lesions is valid.     

Can dynamic gadolinium-enhanced magnetic resonance imaging with chemical shift studies predict the status of adrenal masses?

Endoscopic adrenalectomy represents the new gold standard in the surgical treatment of benign adrenal lesions up to 6 cm. In some cases lesions larger than 10 cm have been removed laparoscopically to offer the patient the advantages of the minimally invasive technique. The larger the diameter of an adrenal lesion, the greater the probability of malignancy. In a prospective study 130 consecutive patients (88 women, 42 men; mean age 47.8 years) with 137 adrenal lesions earmarked for surgery underwent preoperative gadolinium-enhanced magnetic resonance imaging (MRI) with chemical shift studies (CSS). The aim of this study was to predict the status (benign, borderline, malignant) of adrenal lesions by MRI irrespective of tumor size. There were 14 patients with malignant tumors, 3 had borderline tumors (epithelial tumors with high malignant potential), and the remaining 120 had benign adrenal lesions. Five malignant lesions (36%) had a diameter < 6 cm. MRI correctly predicted 11 of 14 malignant tumors (1 malignant pheochromocytoma and 2 adrenocortical carcinomas had false-negative results), 117 of 120 benign lesions, and 2 of 3 borderline lesions. All but two malignant tumors were operated on using open surgery; 82 (68%) of 120 benign adrenal lesions were treated using the transperitoneal laparoscopic approach. Tumor size alone is not suitable for predicting the status of adrenal lesions. Dynamic gadolinium-enhanced MRI with CSS can predict the status of at least 95% of adrenal lesions. Tumors > 6 cm classified as benign by preoperative MRI may be removed laparoscopically by endocrine surgeons experienced in endoscopic adrenalectomy.     

Applicability of laparoscopic adrenalectomy in a prospective study in 150 consecutive patients

HYPOTHESIS: Within a decade, laparascopic adrenalectomy has become the new "gold standard" for the surgical treatment of most adrenal lesions. Designed as a single-center project focused on patients with adrenal lesions, this study should provide an indication of the number of patients requiring surgery who can safely undergo laparoscopy, after consideration of such selection criteria as tumor size and benign or malignant lesion status at magnetic resonance imaging. Furthermore, the access-related complications were analyzed. DESIGN: According to a prospective protocol, 150 consecutive patients selected for adrenal surgery were assigned to transperitoneal endoscopic or open adrenalectomy. SETTING: University hospital section of endocrine surgery. RESULTS: One hundred two patients (68%) were selected for a laparoscopic approach that had to be converted to open surgery in 5 patients (5%). Two malignant cortisol-secreting lesions were operated on laparoscopically because of their small size and benign appearance at magnetic resonance imaging. During histological examination, 14 (29%) of 48 patients assigned to transperitoneal open adrenalectomy had lesions deemed malignant (16 [11%] of 150 patients). The laparoscopic group had significantly fewer complications (9%) than did the open group (21%; P =.04). CONCLUSIONS: By applying defined selection criteria for the treatment of adrenal lesions, transperitoneal endoscopic adrenalectomy can be a safe procedure and may be performed in at least two thirds of patients. The choice of endoscopic or open approach in larger tumors should depend on the results of preoperative imaging studies and the endocrine surgeon's experience in endoscopic adrenal surgery.     

Adrenal myelolipomatous nodules mimicking adrenal neoplasms: report of three cases

The authors describe three cases of adrenal myelolipoma. In the first two, unilateral adrenal masses, assumed to represent adrenal neoplasms, were found during urologic examination; the correct diagnosis was made by frozen-section examination during operation. The third case involved bilateral adrenal lesions diagnosed at autopsy in a patient suspected to have metastatic cancer. Histologic, immunohistochemical and electron microscopic studies revealed polyclonal lesions composed of hematopoietic cells and fat cells. Radiologic recognition and fine-needle biopsy of these lesions are important to avoid unnecessary surgery in asymptomatic cases. Since the lesions cannot be regarded as true neoplasms, the authors suggest that the name myelolipoma should be replaced by the term myelolipomatous nodule.     

Laparoscopic adrenalectomy (LA): keys to success: correct surgical indications, adequate preoperative preparation, surgical team experience

BACKGROUND: Laparoscopic adrenalectomy (LA) has become the surgical procedure of choice for the treatment of most adrenal lesions. Controversy still remains about the treatment for primary and secondary malignant lesions and for pheochromocytoma. MATERIALS AND METHODS: From September 1997 to December 2005, 77 patients were operated on for adrenal tumors in a single center. Three patients had bilateral lesion for a total of 80 adrenalectomies. Selection criteria for laparoscopic treatment included benign characteristics of the lesions regardless of size and absence of virilization syndrome. A multidisciplinary approach was used for adequate preparation of patients with functional lesions. Fifty-five patients were eligible for LA and 22 for open surgery. RESULTS: Mean operative time was 142 minutes (range 45 to 240) in the laparoscopic group (53 patients) and 161 minutes (range 90 to 300) for the open group (24 patients). In 2 patients (4%) conversion to open procedure was necessary for intraoperative bleeding. Laparoscopic surgery in patients with pheochromocytoma was associated with a better intraoperative hemodynamic stability. CONCLUSIONS: LA is the treatment of choice for benign adrenal tumors regardless of size. Appropriate selection of patients, adequate preoperative preparation of patients with functional lesions and expertise in adrenal surgery and advanced laparoscopic skills are necessary to allow reduction of perioperative morbidity and early recovery.     

Surgical implications of underestimation of adrenal tumour size by computed tomography

BACKGROUND: Size of adrenal mass is an important consideration during adrenal surgery, with regard to the choice of surgical approach and management of adrenaloma. The aim of the present study was to evaluate the precision of preoperative computed tomography (CT) on the size estimation of adrenal lesions and to review its potential implications on surgical decision making. METHODS: Records of 110 patients who underwent adrenalectomy for various adrenal pathologies from 1981 to 1997 were reviewed retrospectively. Patients (n = 92) who had documented dimensions of adrenal mass by both preoperative CT and pathological examination were selected for analysis. RESULTS: CT overall underestimated the actual size of adrenal lesions by 16 per cent compared with measurement of resected specimens (mean 3.1 versus 3.6 cm; P < 0.001). There was a significant underestimation of the actual size of adrenal lesions measuring less than 6 cm by CT but not for lesions larger than 6.0 cm. Phaeochromocytoma (n = 17) was the only pathological condition consistently underestimated by CT. CONCLUSION: Conventional CT overall underestimates the real size of adrenal lesions, in particular phaeochromocytoma and adrenal tumours of less than 6.0 cm in size. Surgical decision making based on size should take this limitation into account.     

Our experience in the surgical treatment of the arterial hypertension due to endocrine disturbances

This study is trying to expose our experience in the surgical treatment for adrenal tumors which produce arterial hypertension, experience gained over a period of 25 years. There were 93 adrenalcctomies carried out for these kinds of lesions, out of a total of 125 surgical procedures on the adrenal glands. Best results were obtained for phaeochromocytomas and also for tumors that produce primary hyperaldosteronism. Real advances have been done in the field of adrenal glands diseases by diagnosis and treatment but minimal invasive surgery is best used for all adrenal lesions but phaeochromocytomas in which this approach has to be very well judged.     

Adrenalectomy: indications and options for treatment

The history of adrenal surgery is longstanding. Firstly described in 1889 by Thornton, the open adrenalectomy has been for decades the only surgical approach to adrenal diseases. Nowadays, instead, several approaches to adrenal glands have been described in the literature, such as laparoscopic adrenalectomy, robotic-assisted procedure and single-incision technique. Actually, laparoscopic adrenalectomy is considered as the gold standard treatment for adrenal lesions. In fact, all functional tumors, including pheochromocytoma, are candidates for a laparoscopic approach in the absence of other contraindications. In the adrenal gland surgery, it is important to consider that a multidisciplinary approach which comprises surgeons, anesthesiologists, endocrinologists, and oncologists plays an important role in the management of patients and that the success of the procedure is related also to surgeon experience and hospital volume. This review aims to discuss the indications for adrenalectomy and to describe the different techniques options for the adrenal gland surgery.     

Surgery of the adrenal glands in Cushing's syndrome

Our surgical experience for the Cushing syndrome, reviewed in 23 patients. The accuracy of localizing adrenal lesions increased recently. The present study shows that, adrenal surgery, after accurate diagnosis and localisation, can be performed with low morbidity and mortality.     

Adrenal metastases by renal cell carcinoma: Incidence at nephrectomy

Recently, there have been questions raised as to the results and feasibility of performing renal-sparing procedures for localized renal cell carcinoma. We reviewed the records of 72 patients treated with standard radical nephrectomy to determine the incidence of adrenal involvement and to determine if adrenal lesions were detectable by radiographic methods preoperatively. Four patients had evidence of adrenal involvement for an overall incidence of 5.5 per cent. All had upper pole lesions. Adrenal involvement in each case was apparent at surgery or on preoperative imaging studies. For patients with middle and lower pole localized renal cell carcinoma who have normal findings on preoperative computerized tomography scans, modified radical nephrectomy sparing the adrenal gland may be a surgical alternative to radical nephrectomy.     

肾上腺小肿瘤的后腹腔镜手术治疗体会

目的探讨肾上腺小肿瘤的后腹腔镜手术治疗体会。方法回顾性分析2005年9月至2008年12月我院施行的389例后腹腔镜。肾上腺切除术的临床资料,其中肾上腺小肿瘤96例,分成最初40例组和后期56例组。术前所有病例行CT形态定位检查。所有手术均经后腹膜入路完成。结果96例肾上腺肿瘤平均大小0．7cm（0．5～1．0cm）,其中原醛76例（单侧腺瘤69例、单侧皮质增生7例）,无功能性腺瘤11例,库欣综合症3例,嗜铬细胞瘤2例,黑素瘤1例,髓样脂肪瘤1例,转移癌l例。4例（3．5％）中转开放手术。最初40例组的手术时间明显长于随后的56例组（P〈0．01）,两组术中出血量无明显差异。结论尽管腹腔镜技术是治疗良性肾上腺肿瘤的金标准,但对于肾上腺小肿瘤,腹腔镜手术有一定难度,术中先游离寻找靠近后腹膜的。肾上腺内侧支、充分游离及探查整个肾上腺组织是手术成功的关键。     

Laparoscopic adrenalectomy

Advances in minimally invasive surgery have made it possible to remove solid organs such as the adrenal gland laparoscopically. Several studies have shown that when applied to appropriate operative candidates, laparoscopic adrenalectomy is a safe alternative to conventional open surgery with real advantages in terms of decreasing postoperative pain and length of hospital stay and allowing earlier return to normal activity. The indications for laparoscopic adrenalectomy are essentially the same as those described for open adrenalectomy. We do not recommend laparoscopic adrenalectomy for known primary or metastatic malignant tumors of the adrenal glands, because of the risk of tumor implantation that might compromise the patient's chance for cure, nor do we recommend it for lesions larger than 6 to 8 cm where the chance of malignancy is high. The preoperative preparation, laparoscopic instruments, operative techniques, and potential complications and their treatments are described in this review. Laparoscopic adrenalectomy is becoming the preferred method of surgically treating many adrenal problems. Although conventional surgical approaches will undoubtedly be required to treat certain adrenal lesions, surgeons with an interest in treating patients with adrenal disorders must become proficient in the technique of laparoscopic adrenalectomy. This will allow them to select the most appropriate operative approach for their patients' individual problems.     

Changes of urinary kallikrein excretion and plasma natriuretic factor in a patient with primary aldosteronism with special reference to adrenal histology

High level of urinary kallikrein excretion was observed in a 23-year-old man with primary aldosteronism. Unilateral adrenalectomy improved the clinical symptoms and normalized the urinary concentration of this vasoactive substance. Although plasma atrial natriuretic factor was not elevated, adrenal surgery lowered its concentration. Coexistence of an adrenal adenoma and lesions of nodular hyperplasia were detected in the removed adrenal gland. We summarize the clinical data of this patient and review the literature.     

Determinants for malignancy in surgically treated adrenal lesions

Purpose  

It is difficult to definitively rule out or establish malignancy pre-operatively in patients with adrenal lesions referred for adrenal surgery. The aim of this study was to identify risk factors for a malignant diagnosis in patients treated with adrenalectomy.     

Choriocarcinoma presenting as a spontaneous rupture of an adrenal metastasis: a case report

A 20-year-old woman, who had a history of childbirth, was admitted to the emergency room with an acute abdomen. An abdominal enhanced computed tomography (CT) revealed retroperitoneal hemorrhage, leading to life-threatening, and multiple tumors in the liver. Additionally, chest CT also revealed multiple coin lesions in the lung. These findings strongly indicated a spontaneous rupture of adrenal tumor. We performed exploratory laparotomy. An examination during surgery showed a rupture of adrenal tumor. En bloc resection of adrenal gland, tumor, and the kidney was performed. Pathological finding revealed the adrenal tumor was choriocarcinoma.     

Adrenal-preserving minimally invasive surgery: The role of laparoscopic partial adrenalectomy,cryosurgery, and radiofrequency ablation of the adrenal gland

Adrenalectomy has become the standard of care for the management of hormonally active adrenal masses. Various surgical therapies have been proposed to excise completely or destroy these adrenal lesions, which may be benign or malignant. New minimally invasive, adrenal-sparing procedures have recently been introduced, among them laparoscopic partial adrenalectomy, cryosurgery, and radiofrequency ablation. These procedures focus on reducing patient morbidity and hastening postoperative recovery while preserving normal adrenal tissue. However, questions remain about the risks and benefits associated with routine application of minimally invasive therapies for adrenal-sparing surgery in terms of complete tumor extirpation. Clearly, more experience and longer follow-up is necessary to validate these procedures. Herein we describe the surgical techniques and early results of treatment with adrenal-sparing surgery.     

Open adrenalectomy in the era of laparoscopic surgery: a review

Open adrenalectomy still plays an important role in adrenal surgery. A review of the current literature has been carried out to discuss the main indication to open adrenalectomy with regards to the main adrenal pathologies. The authors underlined the role of open adrenalectomy on the basis of personal experience and a literature review. Indication to open adrenalectomy for adrenal cysts, myelolipomas, pheochromocytomas, metastases, adrenocortical carcinomas and tumour recurrences were analysed and discussed. Open adrenalectomy has still an important role in several adrenal pathologies: it is mandatory in some specific situations, such as big lesions, risk of malignancy, emergency settings and in case of recurrent tumoral disease.     

Cystic type adrenal mass. Clinical-radiologic contribution to 7 cases treated with surgery

The aim of the study was to evaluate the accuracy of our imaging protocol with regard to adrenal masses of cystic nature. Seventy-four adrenal lesions were surgically removed over the period 1998-2002. Of these 7 were diagnosed as cysts or pseudocysts. All the patients were studied by abdominal US, CT and/or MRI. In 2 cases, an adrenal primary malignancy was suspected. The lesions of 2 more patients, radiologically identified as cysts, were interpreted as hepatic echinococcus cyst and mesenteric cyst, respectively; these patients underwent open surgery. In 3 cases an adrenal cystic tumour was correctly diagnosed and a laparoscopic adrenalectomy performed. The histopathological examination of the surgical specimens showed that the preoperative diagnosis failed to ascertain the true nature of the lesion in 4/7 cases (57%). The 2 suspected adrenal carcinomas turned out to be an epithelial cyst and a pseudocyst, respectively; the suspected hepatic echinococcus cyst and the mesenterial cyst were adrenal pseudocysts. Two of the 3 remaining cases were endothelial cysts and the third a pseudocysts. In the presence of adrenal masses of cystic nature, the preoperative diagnosis may easily be inaccurate and adversely influence the surgical approach, especially if a misdiagnosis of primary adrenal malignancy is made.     

Adrenal surgery: Trends during the seventies

Surgical experience with adrenal disease from 1970 to 1979 was reviewed in 315 patients. The pathologic conditions that were encountered were hypercortisolism (74 patients), hyperaldosteronism (46 patients), adrenocortical carcinoma (35 patients), pheochromocytoma (77 patients), and nonfunctioning adenoma (47 patients). In addition, 5 patients with metastatic lesions, 14 with cysts, and 4 with myelolipoma were surgically treated. The accuracy of localizing adrenal lesions increased from about 50 percent to almost 100 percent during the decade studied. The increase was due mainly to the introduction of computerized tomography, the most important advance in the management of adrenal disease. The present study shows that adrenal surgery can be performed with low morbidity and mortality. Operative deaths were confined to patients with malignant disease or increased secretion of cortisol or catecholamines. Only patients with adrenocortical carcinoma (2 year survival probability, 34 percent) or hypercortisolism due to cortical hyperplasia (5 year survival probability, 76 percent) had significantly decreased survival.     

Laparoscopic adrenalectomy in adrenal carcinoma

There is general agreement on the suitability of the laparoscopic approach for benign adrenal lesions against open procedures because of the efficacy and less morbidity. For suspected adrenal malignancies laparoscopic use is controversial. We report our experience in 6 cases of laparoscopic adrenalectomy in patients with the suspicion of adrenal malignancy confined in the gland. In medium a follow up of 24 months (range 12 to 48 months) we observed no recurrences. We concluded that in a suspected adrenal malignancy organ confined laparoscopic adrenalectomy presents the advantage compared with open surgery of reduced morbidity and similar results in the follow up of the patient.