Incidentaloma surgery: Difference between revisions
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==Overview== | ==Overview== | ||
Surgery is the mainstay of treatment for [disease or malignancy]. | Surgery is the mainstay of treatment for [disease or malignancy]. [[Adrenalectomy]] for patients with [[Hyperaldosteronism|aldosteronomas]], [[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. | |||
* The decision to operate should take into account the presence of the [[metabolic]] consequences of [[cortisol]] excess. | * 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]]. | * 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 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. | * 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 | * 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.<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> | ||
* Patients with bilateral [[Adrenal gland|adrenal]] [[Mass|masses]] should be investigated for [[congenital adrenal hyperplasia]].<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> | * Patients with bilateral [[Adrenal gland|adrenal]] [[Mass|masses]] should be investigated for [[congenital adrenal hyperplasia]].<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> | ||
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* [[Adrenalectomy]] for patients with [[Hyperaldosteronism|aldosteronomas]], [[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> | * [[Adrenalectomy]] for patients with [[Hyperaldosteronism|aldosteronomas]], [[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> | ||
* [[Laparoscopic surgery|Laparoscopic transabdomina]]<nowiki/>l and [[retroperitoneal]] approaches have been used successfully for non | * [[Laparoscopic surgery|Laparoscopic transabdomina]]<nowiki/>l and [[retroperitoneal]] approaches have been used successfully for non[[Metastasis|metastatic]] [[abdominal]] [[Pheochromocytoma|pheochromocytomas]].<sup>[[Pheochromocytoma surgery#cite note-pmid21494137-2|[2]]]</sup> | ||
* There are | * 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 intraoperative [[tumor]] capsule rupture, [[hypertensive crisis]], [[myocardial infarctions]], or [[Stroke|cerebrovascular hemorrhages]]. [[Hemodynamic instability]] after [[tumor]] resection is possible. [[Hypoglycemia]] can occur after tumor resection due to unopposed [[insulin]] effect after declining of [[catecholamines]] levels.<sup>[[Pheochromocytoma surgery#cite note-pmid25188716-3|[3]]]</sup> | * Major intraoperative complications include intraoperative [[tumor]] capsule rupture, [[hypertensive crisis]], [[myocardial infarctions]], or [[Stroke|cerebrovascular hemorrhages]]. [[Hemodynamic instability]] after [[tumor]] resection is possible. [[Hypoglycemia]] can occur after tumor resection due to unopposed [[insulin]] effect after declining of [[catecholamines]] levels.<sup>[[Pheochromocytoma surgery#cite note-pmid25188716-3|[3]]]</sup> | ||
* Severe [[hypotension]] can occur after removal of the gland due to decreased [[catecholamines]] level in [[blood]] and [[Downregulation|down-regulation]] of [[adrenergic receptors]]. It can be controlled by [[vasopressors]] induction.<sup>[[Pheochromocytoma surgery#cite note-pmid14734011-4|[4]]]</sup> | * Severe [[hypotension]] can occur after removal of the gland due to decreased [[catecholamines]] level in [[blood]] and [[Downregulation|down-regulation]] of [[adrenergic receptors]]. It can be controlled by [[vasopressors]] induction.<sup>[[Pheochromocytoma surgery#cite note-pmid14734011-4|[4]]]</sup> | ||
Revision as of 15:04, 5 September 2017
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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]. Adrenalectomy for patients with aldosteronomas, 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.
- 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[3]
- 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.[4]
- 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.[5]
- 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 for patients with aldosteronomas, pheochromocytoma, cortisol-secreting tumors, and adrenal incidentalomas is safe and effective.[7]
- Laparoscopic transabdominal and retroperitoneal approaches have been used successfully for nonmetastatic abdominal pheochromocytomas.[2]
- 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 intraoperative tumor capsule rupture, hypertensive crisis, myocardial infarctions, or cerebrovascular hemorrhages. Hemodynamic instability after tumor resection is possible. Hypoglycemia can occur after tumor resection due to unopposed insulin effect after declining of catecholamines levels.[3]
- Severe hypotension can occur after removal of the gland due to decreased catecholamines level in blood and down-regulation of adrenergic receptors. It can be controlled by vasopressors induction.[4]
- Risk factors for complications during surgery include:
- High plasma norepinephrine concentration
- Larger tumor size
- Postural hypotension after α-blockade, and a mean arterial pressure above 100 mm Hg.
- The patient should receive glucocorticoid stress coverage in bilateral adrenalectomy.
References
- ↑ 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.
- ↑ 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.
- ↑ 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.