Incidentaloma surgery

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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

Comparison of Open and laparoscopic adrenalectomy
Laparoscopic adrenalectomy (LA) 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.[3]
  • Recurrence and peritoneal spread were more common in the LA group.[4]
  • Higher incidence of incomplete resections is found in LA.
  • Peritoneal carcinomatosis (spread) occurred in only 25% of cases.
  • Recurrence rate is 100%.[5]
  • 16% of patients had positive margins after the surgery.
  • American Association of Clinical Endocrinologists and the American Association of Endocrine Surgeons recommended OA as the procedure of choice.[6]
  • the 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:[7][8][9][10]

  • 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

References

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. 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.
  10. 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.
  11. 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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