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
- Surgery is the mainstay of treatment for incidentaloma.[1][2]
- 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.
- Laparoscopic transabdominal and retroperitoneal approaches have been used successfully for nonmetastatic abdominal pheochromocytomas.
- 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.
- Patients with bilateral adrenal masses should be investigated for congenital adrenal hyperplasia.
Comparison of Open and laparoscopic adrenalectomy
| Laparoscopic adrenalectomy (LA) | Open adrenalectomy (OA) |
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Indications
The indications of surgery for incidentaloma include:[7][8][9][10]
- 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 sub-clinical Cushing's syndrome should be selected for surgery based upon the clinical parameters discussed above.
- 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.
- 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
- Adrenalectomy for patients with hyperaldosteronism, pheochromocytoma, cortisol-secreting tumors, and adrenal incidentalomas is safe and effective.[11]
- Risk factors for complications during surgery include:
- High plasma norepinephrine concentration
- Larger tumor size
- Postural hypotension after α-blockade
- A mean arterial pressure above 100 mm Hg
- 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:[3][4]
- Intraoperative tumor capsule rupture
- Hypertensive crisis
- Myocardial infarctions
- Cerebrovascular hemorrhages
- Hemodynamic instability after tumor resection (due to decreased catecholamines level in blood and down-regulation of adrenergic receptors)
- Hypoglycemia can occur after tumor resection (due to unopposed insulin effect after declining of catecholamines levels)
References
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.