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
- 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 (1, 21, 72)
- 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).
- 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. 52
- Patients with bilateral adrenal masses should be investigated for congenital adrenal hyperplasia [53].
Indications
- 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 [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.
Adrenalectomy
- Adrenalectomy for patients with aldosteronomas, pheochromocytoma, cortisol-secreting tumors, and adrenal incidentalomas is safe and effective [54].
- Laparoscopic transabdominal and retroperitoneal approaches have been used successfully for non-metastatic abdominal pheochromocytomas.[2]
- There are less 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.