Incidentaloma surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Overview

Surgery is the mainstay of treatment for [disease or malignancy].

Surgery

  • 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.
  • 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.[1]
  • Patients with bilateral adrenal masses should be investigated for congenital adrenal hyperplasia.[2]

Indications

  • 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 subclinical Cushing's syndrome should be selected for surgery based upon the clinical parameters discussed above.[3]
  • 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.[4]
  • 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 cutoff.

Adrenalectomy[5]

  • Adrenalectomy for patients with aldosteronomas, pheochromocytoma, cortisol-secreting tumors, and adrenal incidentalomas is safe and effective.[6]

References

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.

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