Incidentaloma surgery
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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
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)
Unilateral adrenal masses
All patients with documented pheochromocytoma and adrenocortical cancer should undergo prompt surgical intervention because untreated pheochromocytoma may result in significant cardiovascular complications.Alpha blockade should be given before patients undergo adrenalectomy.
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 [47].
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 [2,14]. 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. As an example, most clinicians would advise resecting a uniform hypodense (9 Hounsfield unit [HU]) 3.7 cm adrenal incidentaloma in a 23-year-old woman, whereas most clinicians would choose serial imaging follow-up in an 83-year-old woman with a uniform hypodense (9 HU) 4.7 cm adrenal incidentaloma. Surgical resection should be considered in this example of a young woman because adrenal cortical nodularity is, in part, a function of aging and such a finding in a 23-year-old is not normal. In addition, the alternative would be long-term imaging follow-up, which is associated with clinically significant expense, worry, and risks. Before surgery, all patients should undergo appropriate testing for functional tumors.
Adrenal myelolipoma is a benign tumor composed of mature fat and interspersed hematopoietic elements that resemble bone marrow. On computed imaging, the presence of large amounts of macroscopic fat in an adrenal mass is diagnostic of a myelolipoma (image 5) [52]. 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.
Bilateral adrenal masses
The management of bilateral adrenal masses is different from that for unilateral masses.
In cases of subclinical bilateral macronodular adrenal hyperplasia (BMAH), size is not an indication for surgery, as some can be as large as 5 to 10 cm with insufficient hormone production to necessitate surgery. Patients with bilateral adrenal masses should be investigated for congenital adrenal hyperplasia [53].
Adrenalectomy
Adrenalectomy for patients with aldosteronomas, pheochromocytoma, cortisol-secreting tumors, and adrenal incidentalomas is safe and effective [54]. An adrenalectomy may be done laparoscopically, endoscopically via the posterior approach, or as an open procedure. Laparoscopic adrenalectomy, compared with open adrenalectomy, is associated with less pain, shorter hospitalization time, less blood loss, and faster recovery [55]. The laparoscopic approach is used for most adrenal masses.
In patients with known or suspected adrenal carcinoma, the laparoscopic approach should only be considered if the adrenal mass is <10 cm and does not appear to be locally invasive [56,57].
An open adrenalectomy is recommended for all large (>10 cm) adrenal masses, including those benign imaging features, as the adrenal mass may be diagnosed as malignant on a definitive histologic review [56,58-61].