Incidentaloma surgery
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Incidentaloma Microchapters |
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Diagnosis |
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Incidentaloma surgery On the Web |
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American Roentgen Ray Society Images of Incidentaloma surgery |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:
Overview
Surgical intervention is not recommended for the management of [disease name].
OR
Surgery is not the first-line treatment option for patients with [disease name]. Surgery is usually reserved for patients with either [indication 1], [indication 2], and [indication 3]
OR
The mainstay of treatment for [disease name] is medical therapy. Surgery is usually reserved for patients with either [indication 1], [indication 2], and/or [indication 3].
OR
The feasibility of surgery depends on the stage of [malignancy] at diagnosis.
OR
Surgery is the mainstay of treatment for [disease or malignancy].
Surgery
With regard to developing SCS in a nonfunctioning adenoma, Barzon et al. (60) followed 130 patients with an adrenal incidentaloma, and the estimated cumulative risk of developing SCS at 1 and 5 yr was 3.8 and 6.6%, respectively.
Most studies have reported a higher prevalence of hypertension, obesity, insulin resistance, dyslipidemia, and osteoporosis in patients with SCS (22, 52, 53, 61–66).
There is growing evidence for the deleterious effects of excess cortisol on bone in patients of both sexes with SCS.
A high prevalence of vertebral fractures (43 to 72%) has been reported in patients with subclinical hypercortisolism (67–69).
A possible role of glucocorticoid receptor polymorphism in determining metabolic and bone complications in patients with adrenal incidentaloma has recently been suggested (70).
The decision to operate should take into account the presence of the metabolic consequences of cortisol excess, as well as the severity of the hypothalamic-pituitary-adrenal (HPA) axis abnormality. In general, the more severe the abnormality of the HPA axis, the more likely the patient would benefit from surgery. In a recent retrospective study of 41 patients with adrenal incidentaloma and SCS, 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 (71). Until the results of prospective studies are available, 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 (1, 21, 72)
Perioperative management of patients with SCS
Patients with Cushing’s syndrome or SCS have adequate circulating glucocorticoids and therefore do not require glucocorticoid therapy during surgery.
Such patients can safely undergo surgical resection of their tumor, have their cortisol levels measured in the morning of postoperative d 1
and then be started on hydrocortisone 30 mg in the morning and 10 mg in the early afternoon until the result of the cortisol level becomes available (73).
this would provide an early and accurate evaluation of surgical success in patients with underlying Cushing’s syndrome or SCS.
Another approach would be to cover all patients with glucocorticoids perioperatively and evaluate their HPA axis at a later date (71, 74).
Aldosteronoma
Preoperative and surgical management
- The majority of patients with primary aldosteronism need to proceed with bilateral adrenal venous sampling to confirm the presence of a unilateral source for hyperaldosteronism.
- Some experts recommend adrenal vein sampling in all patients with primary aldosteronism older than 40 yr due to the increased prevalence of adrenal incidentaloma in such a population (118).
- Adrenalectomy in patients with a documented unilateral source of primary aldosteronism is more cost effective compared with lifelong medical therapy.
- Medical therapy with mineralocorticoid receptor antagonists should be reserved for those who are unable or unwilling to undergo surgery (44).
- Laparoscopic adrenalectomy compared to an open procedure is associated with a shorter hospital stay, fewer complications, and faster recovery.
- Resection of the adrenal tumor in a patient with APA will result in resolution of hypokalemia and improvement in hypertension in almost all patients.
Postoperative management
- Potassium supplementation and mineralocorticoid receptor antagonists should be stopped on postoperative day1
- Close monitoring of serum potassium.
- A temporary state of hypoaldosteronism may also develop in some patients with primary aldosteronism postoperatively.
- In the majority of cases, this condition can be managed by increasing salt intake.