Incidentaloma surgery: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Incidentaloma}} | {{Incidentaloma}} | ||
{{CMG}}; {{AE}} | {{CMG}}; {{AE}} {{MAD}} | ||
==Overview== | ==Overview== | ||
Surgery is the mainstay of treatment for adrenal incidentaloma. [[Adrenalectomy]] for patients with [[hyperaldosteronism]], [[pheochromocytoma]], [[Cortisol-secreting tumor|cortisol-secreting tumors]], and [[Adrenal gland|adrenal]] incidentalomas is safe and effective. A reasonable strategy may be to consider [[adrenalectomy]] for younger patients and those with new onset or a worsening of underlying comorbidities such as [[diabetes mellitus]], [[hypertension]], [[obesity]], or [[osteoporosis]]. All patients with documented [[pheochromocytoma]] and [[Adrenocortical carcinoma|adrenocortical cancer]] should undergo prompt surgical intervention. Risk factors for complications during surgery include high [[plasma]] [[norepinephrine]] concentration and larger [[tumor]] size. | |||
==Surgery== | ==Surgery== | ||
* Surgery is the mainstay of treatment for incidentaloma.<ref name="pmid20625655">{{cite journal| author=Mermejo LM, Elias Junior J, Saggioro FP, Tucci Junior S, Castro Md, Moreira AC et al.| title=Giant adrenal myelolipoma associated with 21-hydroxylase deficiency: unusual association mimicking an androgen-secreting adrenocortical carcinoma. | journal=Arq Bras Endocrinol Metabol | year= 2010 | volume= 54 | issue= 4 | pages= 419-24 | pmid=20625655 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20625655 }}</ref><ref name="pmid19168848">{{cite journal| author=Craig WD, Fanburg-Smith JC, Henry LR, Guerrero R, Barton JH| title=Fat-containing lesions of the retroperitoneum: radiologic-pathologic correlation. | journal=Radiographics | year= 2009 | volume= 29 | issue= 1 | pages= 261-90 | pmid=19168848 | doi=10.1148/rg.291085203 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19168848 }}</ref> | |||
** The decision to operate should take into account the presence of the [[metabolic]] consequences of [[cortisol]] excess. | |||
** A reasonable strategy may be to consider [[adrenalectomy]] for younger patients and those with new onset or a worsening of underlying comorbidities such as [[diabetes mellitus]], [[hypertension]], [[obesity]], or [[osteoporosis]]. | |||
** [[Laparoscopic surgery|Laparoscopic transabdomina]]<nowiki/>l and [[retroperitoneal]] approaches have been used successfully for non[[Metastasis|metastatic]] [[abdominal]] [[Pheochromocytoma|pheochromocytomas]]. | |||
** There was a significant improvement in [[blood pressure]] and fasting [[Blood sugar|blood glucose]] in patients who underwent surgery, but a worsening of [[blood pressure]] and fasting [[blood glucose]] in those who chose to be managed conservatively during a follow-up period of 18–48 months. | |||
** Although [[Adrenal gland|adrenal]] [[Adrenolipoma|myelolipomas]] may grow over time, they can usually be followed without surgical excision. However, when larger than 6 cm in diameter or when causing local mass-effect symptoms, surgical removal should be considered. | |||
** Patients with bilateral [[Adrenal gland|adrenal]] [[Mass|masses]] should be investigated for [[congenital adrenal hyperplasia]]. | |||
=====Comparison of Open and laparoscopic adrenalectomy===== | |||
{| class="wikitable" | |||
!Laparoscopic adrenalectomy (LA) | |||
The decision to operate should take into account the presence of the metabolic consequences of cortisol excess, | !Open adrenalectomy (OA) | ||
|- | |||
| | |||
* LA has shown lower morbidity, less pain, shorter hospital stays, and decreased recovery time if compared with open adrenalectomy | |||
* Application of [[laparoscopic]] instruments can result in the shedding of malignant cells.<ref name="pmid23158185">{{cite journal| author=Miller BS, Gauger PG, Hammer GD, Doherty GM| title=Resection of adrenocortical carcinoma is less complete and local recurrence occurs sooner and more often after laparoscopic adrenalectomy than after open adrenalectomy. | journal=Surgery | year= 2012 | volume= 152 | issue= 6 | pages= 1150-7 | pmid=23158185 | doi=10.1016/j.surg.2012.08.024 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23158185 }}</ref> | |||
* Recurrence and [[Peritoneal|peritonea]]<nowiki/>l spread were more common in the LA group.<ref name="pmid16360394">{{cite journal| author=Gonzalez RJ, Shapiro S, Sarlis N, Vassilopoulou-Sellin R, Perrier ND, Evans DB et al.| title=Laparoscopic resection of adrenal cortical carcinoma: a cautionary note. | journal=Surgery | year= 2005 | volume= 138 | issue= 6 | pages= 1078-85; discussion 1085-6 | pmid=16360394 | doi=10.1016/j.surg.2005.09.012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16360394 }}</ref> | |||
* Higher [[incidence]] of incomplete [[Resection|resections]] is found in LA. | |||
* [[Peritoneal carcinomatosis]] ([[Spread of the cancer|spread]]) occurred in only 25% of cases. | |||
* Recurrence rate is 100%.<ref name="pmid19851811">{{cite journal| author=Grubbs EG, Callender GG, Xing Y, Perrier ND, Evans DB, Phan AT et al.| title=Recurrence of adrenal cortical carcinoma following resection: surgery alone can achieve results equal to surgery plus mitotane. | journal=Ann Surg Oncol | year= 2010 | volume= 17 | issue= 1 | pages= 263-70 | pmid=19851811 | doi=10.1245/s10434-009-0716-x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19851811 }}</ref> | |||
* 16% of patients had positive margins after the surgery. | |||
and | | | ||
* American Association of Clinical Endocrinologists and the American Association of Endocrine Surgeons recommended OA as the procedure of choice.<ref name="pmid19632968">{{cite journal| author=Zeiger MA, Thompson GB, Duh QY, Hamrahian AH, Angelos P, Elaraj D et al.| title=American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons Medical Guidelines for the Management of Adrenal Incidentalomas: executive summary of recommendations. | journal=Endocr Pract | year= 2009 | volume= 15 | issue= 5 | pages= 450-3 | pmid=19632968 | doi=10.4158/EP.15.5.450 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19632968 }}</ref> | |||
* the [[Peritoneal carcinomatosis|peritoneal spread]] is 60% with significantly earlier recurrence. | |||
* 30% of patients had positive margins. | |||
* Recurrence rate of 86% in the OA group | |||
* | * Survival for patients with stage 2 was longer in those undergoing OA. | ||
|} | |||
==== Indications ==== | |||
The indications of surgery for incidentaloma include:<ref name="pmid21632813">{{cite journal| author=Zeiger MA, Siegelman SS, Hamrahian AH| title=Medical and surgical evaluation and treatment of adrenal incidentalomas. | journal=J Clin Endocrinol Metab | year= 2011 | volume= 96 | issue= 7 | pages= 2004-15 | pmid=21632813 | doi=10.1210/jc.2011-0085 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21632813 }}</ref><ref name="pmid19247023">{{cite journal| author=Toniato A, Merante-Boschin I, Opocher G, Pelizzo MR, Schiavi F, Ballotta E| title=Surgical versus conservative management for subclinical Cushing syndrome in adrenal incidentalomas: a prospective randomized study. | journal=Ann Surg | year= 2009 | volume= 249 | issue= 3 | pages= 388-91 | pmid=19247023 | doi=10.1097/SLA.0b013e31819a47d2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19247023 }}</ref><ref name="pmid6648806">{{cite journal| author=Henley DJ, van Heerden JA, Grant CS, Carney JA, Carpenter PC| title=Adrenal cortical carcinoma--a continuing challenge. | journal=Surgery | year= 1983 | volume= 94 | issue= 6 | pages= 926-31 | pmid=6648806 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6648806 }}</ref>'''<ref name="pmid216328132">{{cite journal| author=Zeiger MA, Siegelman SS, Hamrahian AH| title=Medical and surgical evaluation and treatment of adrenal incidentalomas. | journal=J Clin Endocrinol Metab | year= 2011 | volume= 96 | issue= 7 | pages= 2004-15 | pmid=21632813 | doi=10.1210/jc.2011-0085 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21632813 }}</ref>'''<nowiki/> | |||
* All patients with documented [[pheochromocytoma]] and [[Adrenocortical carcinoma|adrenocortical cancer]] should undergo prompt surgical intervention because untreated [[pheochromocytoma]] may result in significant [[cardiovascular]] complications. | |||
* Patients with [[Adrenocortical carcinoma|adrenocortical cancer]] or lesions suspicious for [[Adrenocortical carcinoma|adrenocortical cancer]] should also undergo prompt [[adrenalectomy]] as their disease may progress rapidly. | |||
* Patients with [[aldosterone]]-producing [[adenomas]] should be offered surgery to cure [[aldosterone]] excess. | |||
* Some patients with documented [[subclinical|sub-clinical]] [[Cushing's syndrome]] should be selected for surgery based upon the clinical parameters discussed above. | |||
* [[Adrenal mass causes|Adrenal masses]] with either suspicious imaging [[phenotype]] or size larger than 4 cm should be considered for resection because a substantial fraction will be [[Adrenocortical carcinoma|adrenocortical carcinomas.]] | |||
* | * The clinical scenario and patient age frequently guide the management decisions in patients who have adrenal incidentalomas that fall on either side of the 4 cm diameter cut-off. | ||
== | ==== Complications ==== | ||
* [[Adrenalectomy]] for patients with [[hyperaldosteronism]], [[pheochromocytoma]], [[Cortisol-secreting tumor|cortisol-secreting tumors]], and [[Adrenal gland|adrenal]] incidentalomas is safe and effective.<ref name="pmid18164803">{{cite journal| author=Liao CH, Lai MK, Li HY, Chen SC, Chueh SC| title=Laparoscopic adrenalectomy using needlescopic instruments for adrenal tumors less than 5cm in 112 cases. | journal=Eur Urol | year= 2008 | volume= 54 | issue= 3 | pages= 640-6 | pmid=18164803 | doi=10.1016/j.eururo.2007.12.028 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18164803 }}</ref> | |||
* Risk factors for complications during surgery include: | |||
**High [[plasma]] [[norepinephrine]] concentration | |||
**Larger [[tumor]] size | |||
**[[Postural hypotension]] after [[Alpha blocker|α-blockade]] | |||
**A [[mean arterial pressure]] above 100 mm Hg | |||
* There are fewer complications associated with [[laparoscopic surgery]] than with [[open surgery]]. [[Catecholamine]] secretion falls to a normal level within a week. | |||
* Major intraoperative complications include:<sup>[[Pheochromocytoma surgery#cite note-pmid25188716-3|[3]]]</sup><sup>[[Pheochromocytoma surgery#cite note-pmid14734011-4|[4]]]</sup> | |||
**Intraoperative [[tumor]] capsule rupture | |||
**[[Hypertensive crisis]] | |||
**[[Myocardial infarctions]] | |||
**[[Stroke|Cerebrovascular hemorrhages]] | |||
**[[Hemodynamic instability]] after [[tumor]] resection (due to decreased [[catecholamines]] level in [[blood]] and [[Downregulation|down-regulation]] of [[adrenergic receptors]]) | |||
**[[Hypoglycemia]] can occur after tumor resection (due to unopposed [[insulin]] effect after declining of [[catecholamines]] levels) | |||
==References== | ==References== | ||
Latest revision as of 16:17, 9 November 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammed Abdelwahed M.D[2]
Overview
Surgery is the mainstay of treatment for adrenal incidentaloma. Adrenalectomy for patients with hyperaldosteronism, pheochromocytoma, cortisol-secreting tumors, and adrenal incidentalomas is safe and effective. A reasonable strategy may be to consider adrenalectomy for younger patients and those with new onset or a worsening of underlying comorbidities such as diabetes mellitus, hypertension, obesity, or osteoporosis. All patients with documented pheochromocytoma and adrenocortical cancer should undergo prompt surgical intervention. Risk factors for complications during surgery include high plasma norepinephrine concentration and larger tumor size.
Surgery
- Surgery is the mainstay of treatment for incidentaloma.[1][2]
- The decision to operate should take into account the presence of the metabolic consequences of cortisol excess.
- A reasonable strategy may be to consider adrenalectomy for younger patients and those with new onset or a worsening of underlying comorbidities such as diabetes mellitus, hypertension, obesity, or osteoporosis.
- Laparoscopic transabdominal and retroperitoneal approaches have been used successfully for nonmetastatic abdominal pheochromocytomas.
- There was a significant improvement in blood pressure and fasting blood glucose in patients who underwent surgery, but a worsening of blood pressure and fasting blood glucose in those who chose to be managed conservatively during a follow-up period of 18–48 months.
- Although adrenal myelolipomas may grow over time, they can usually be followed without surgical excision. However, when larger than 6 cm in diameter or when causing local mass-effect symptoms, surgical removal should be considered.
- Patients with bilateral adrenal masses should be investigated for congenital adrenal hyperplasia.
Comparison of Open and laparoscopic adrenalectomy
| Laparoscopic adrenalectomy (LA) | Open adrenalectomy (OA) |
|---|---|
|
|
Indications
The indications of surgery for incidentaloma include:[7][8][9][10]
- All patients with documented pheochromocytoma and adrenocortical cancer should undergo prompt surgical intervention because untreated pheochromocytoma may result in significant cardiovascular complications.
- Patients with adrenocortical cancer or lesions suspicious for adrenocortical cancer should also undergo prompt adrenalectomy as their disease may progress rapidly.
- Patients with aldosterone-producing adenomas should be offered surgery to cure aldosterone excess.
- Some patients with documented sub-clinical Cushing's syndrome should be selected for surgery based upon the clinical parameters discussed above.
- Adrenal masses with either suspicious imaging phenotype or size larger than 4 cm should be considered for resection because a substantial fraction will be adrenocortical carcinomas.
- The clinical scenario and patient age frequently guide the management decisions in patients who have adrenal incidentalomas that fall on either side of the 4 cm diameter cut-off.
Complications
- Adrenalectomy for patients with hyperaldosteronism, pheochromocytoma, cortisol-secreting tumors, and adrenal incidentalomas is safe and effective.[11]
- Risk factors for complications during surgery include:
- High plasma norepinephrine concentration
- Larger tumor size
- Postural hypotension after α-blockade
- A mean arterial pressure above 100 mm Hg
- There are fewer complications associated with laparoscopic surgery than with open surgery. Catecholamine secretion falls to a normal level within a week.
- Major intraoperative complications include:[3][4]
- Intraoperative tumor capsule rupture
- Hypertensive crisis
- Myocardial infarctions
- Cerebrovascular hemorrhages
- Hemodynamic instability after tumor resection (due to decreased catecholamines level in blood and down-regulation of adrenergic receptors)
- Hypoglycemia can occur after tumor resection (due to unopposed insulin effect after declining of catecholamines levels)
References
- ↑ Mermejo LM, Elias Junior J, Saggioro FP, Tucci Junior S, Castro Md, Moreira AC; et al. (2010). "Giant adrenal myelolipoma associated with 21-hydroxylase deficiency: unusual association mimicking an androgen-secreting adrenocortical carcinoma". Arq Bras Endocrinol Metabol. 54 (4): 419–24. PMID 20625655.
- ↑ Craig WD, Fanburg-Smith JC, Henry LR, Guerrero R, Barton JH (2009). "Fat-containing lesions of the retroperitoneum: radiologic-pathologic correlation". Radiographics. 29 (1): 261–90. doi:10.1148/rg.291085203. PMID 19168848.
- ↑ Miller BS, Gauger PG, Hammer GD, Doherty GM (2012). "Resection of adrenocortical carcinoma is less complete and local recurrence occurs sooner and more often after laparoscopic adrenalectomy than after open adrenalectomy". Surgery. 152 (6): 1150–7. doi:10.1016/j.surg.2012.08.024. PMID 23158185.
- ↑ Gonzalez RJ, Shapiro S, Sarlis N, Vassilopoulou-Sellin R, Perrier ND, Evans DB; et al. (2005). "Laparoscopic resection of adrenal cortical carcinoma: a cautionary note". Surgery. 138 (6): 1078–85, discussion 1085-6. doi:10.1016/j.surg.2005.09.012. PMID 16360394.
- ↑ Grubbs EG, Callender GG, Xing Y, Perrier ND, Evans DB, Phan AT; et al. (2010). "Recurrence of adrenal cortical carcinoma following resection: surgery alone can achieve results equal to surgery plus mitotane". Ann Surg Oncol. 17 (1): 263–70. doi:10.1245/s10434-009-0716-x. PMID 19851811.
- ↑ Zeiger MA, Thompson GB, Duh QY, Hamrahian AH, Angelos P, Elaraj D; et al. (2009). "American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons Medical Guidelines for the Management of Adrenal Incidentalomas: executive summary of recommendations". Endocr Pract. 15 (5): 450–3. doi:10.4158/EP.15.5.450. PMID 19632968.
- ↑ Zeiger MA, Siegelman SS, Hamrahian AH (2011). "Medical and surgical evaluation and treatment of adrenal incidentalomas". J Clin Endocrinol Metab. 96 (7): 2004–15. doi:10.1210/jc.2011-0085. PMID 21632813.
- ↑ Toniato A, Merante-Boschin I, Opocher G, Pelizzo MR, Schiavi F, Ballotta E (2009). "Surgical versus conservative management for subclinical Cushing syndrome in adrenal incidentalomas: a prospective randomized study". Ann Surg. 249 (3): 388–91. doi:10.1097/SLA.0b013e31819a47d2. PMID 19247023.
- ↑ Henley DJ, van Heerden JA, Grant CS, Carney JA, Carpenter PC (1983). "Adrenal cortical carcinoma--a continuing challenge". Surgery. 94 (6): 926–31. PMID 6648806.
- ↑ Zeiger MA, Siegelman SS, Hamrahian AH (2011). "Medical and surgical evaluation and treatment of adrenal incidentalomas". J Clin Endocrinol Metab. 96 (7): 2004–15. doi:10.1210/jc.2011-0085. PMID 21632813.
- ↑ Liao CH, Lai MK, Li HY, Chen SC, Chueh SC (2008). "Laparoscopic adrenalectomy using needlescopic instruments for adrenal tumors less than 5cm in 112 cases". Eur Urol. 54 (3): 640–6. doi:10.1016/j.eururo.2007.12.028. PMID 18164803.