Effectiveness of partial adrenalectomy for concomitant hypertension in patients with nonfunctional adrenal adenoma

Metabolic complications and clinical outcomes of non-functioning adrenal incidentalomas: a systematic review and meta-analysis

BACKGROUND

Increased detection of non-functioning adrenal incidentalomas (NFAI) due to widespread abdominal imaging may underestimate associated metabolic risks. To examine NFAI's impact on metabolic comorbidities and evaluate outcomes in surgical and non-surgical management, including changes in NFAI characteristics during follow-up.

METHODS

Meta-analysis of studies from PubMed, Embase, Cochrane Library, and Web of Science (January 2000 to May 2024). Studies focusing on patients with serum cortisol levels ≤ 50 nmol/L after 1 mg dexamethasone suppression test (DST). Prevalence of hypertension, diabetes, obesity, and lipid disorders before and after follow-up. Tumor growth (> 10 mm increase) and functional changes (1 mg DST retest) were assessed.

RESULTS

Eighteen studies met inclusion criteria (n = 2,059). In the non-surgical group, diabetes (RR: 1.33, 95% CI: 1.07-1.65) and lipid disorders (RR: 1.22, 95% CI: 1.07-1.38) increased significantly, while hypertension (RR: 1.07, 95% CI: 0.99-1.16) and obesity (RR: 1.05, 95% CI: 0.91-1.21) showed no significant change. Surgical intervention significantly improved hypertension (RR: 0.67, 95% CI: 0.52-0.86). During mean follow-up of 46.1 months, 4% (95% CI: 2%- 8%) of NFAI enlarged > 10 mm, while 8% (95% CI: 5%- 14%) became functional during 45.1 months of follow-up.

CONCLUSIONS

In patients with NFAI, subtle hormone secretion may exist despite current diagnostic criteria suggesting non-functionality. Such tumors show significant associations with metabolic disorders, particularly diabetes mellitus and dyslipidemia. Future research should focus on developing more sensitive diagnostic methods and establishing evidence-based surgical intervention criteria through prospective studies.

Prevalence and Incidence of Dementia in Patients With Non-Overtly Functional Adrenal Tumours

OBJECTIVE

To investigate the prevalence and incidence of dementia in patients with non-overtly functional adrenal tumours (NOFATs).

DESIGN

A national retrospective register-based study was conducted on patients diagnosed with NOFAT and controls diagnosed between 2005 and 2019, in Sweden. Individuals diagnosed with overt adrenal hormone excess or previous malignancies were excluded. Sensitivity analyses were performed in subgroups with a combination of gallbladder/biliary tract/pancreatic disease. and acute appendicitis, as well as 3- and 12-months of malignancy-free survival.

MEASUREMENTS

Prevalence and incidence of dementia. The secondary outcomes were Alzheimer's disease and vascular dementia.

RESULTS

Among 20,390 cases, 12,120 (59.4%) were women, and the median (IQR) age was 66 (57-73) years. Among the 125,392 controls, 69,994 (55.8%) were women and the median (IQR) age was 66 (57-73) years. Patients with NOFATs had a lower prevalence of dementia compared to controls (odds ratio [OR] 0.58, 95% CI 0.50-0.68, adjusted OR [aOR] 0.47, 95% CI 0.40-0.56). During the follow-up period (median 4.9 years, IQR 2.2-8.2), incidence of dementia was similar in NOFATs and controls (hazard ratio [HR] 1.05, 95% CI 0.97-1.15, adjusted HR [aHR] 1.06, 95% CI 0.97-1.15). Similar results obtained for Alzheimer's dementia (aOR 0.44, 95% CI 0.34-0.57; aHR 0.94, 95% CI 0.80-1.10) and vascular dementia (OR 0.71, 95% CI 0.52-0.94, aOR 0.48, 95% CI 0.35-0.64; HR 1.29, 95% CI 1.08-1.53, aHR 1.13, 95% CI 0.95-1.35) as well as in the sensitivity analyses. Adrenalectomy did not change the results.

CONCLUSION

NOFAT was not associated with an increased risk of dementia.

Blood pressure improvement after resection of non-functioning adrenal adenomas: influencing factors and serum metabolic features

Introduction

Non-functioning adrenal adenomas (NFAs) are typically regarded as benign tumors that lack hormonal secretion. However, emerging evidence has shown that some patients with NFAs and hypertension experience improvements in blood pressure after adrenalectomy, indicating a potential correlation between NFAs and hypertension. Nevertheless, the precise mechanisms that underpin this phenomenon remain elusive.

Methods

We collected data from all patients with adrenal adenomas who underwent unilateral laparoscopic partial or total adrenalectomy at the First Affiliated Hospital of Xi'an Jiaotong University in 2023. A statistical analysis was conducted on factors such as tumor diameter, duration of hypertension, BMI, and age. Additionally, we gathered serum samples from six patients who experienced postoperative blood pressure improvement and six patients who did not. These samples were subjected to targeted and untargeted metabolomic analyses to identify significant serum metabolites.

Results

Our findings revealed that 50.9% of patients with NFAs and hypertension experienced blood pressure improvement after surgery. Additionally, patients in the improvement group (IG) exhibited larger tumor diameters alongside shorter durations of hypertension compared to their counterparts in the nonimprovement group (NIG). Untargeted metabolomic analysis identified 89 differentially abundant metabolites in the serum between the IG and NIG. In particular, we found that guanidinoacetic acid (GAA), a precursor of creatine synthesis that possibly participates in the occurrence of hypertension, was enriched in patients in the IG and reduced after surgery.

Discussion

The findings of our study indicated that duration of hypertension and tumor diameter may exert an influence on the extent of postoperative blood pressure improvement, and NFAs might promote hypertension through GAA-related creatine metabolism.

Identification of risk factors for postoperative persistent hypertension in patients with pheochromocytoma

BACKGROUND

Surgical resection is the primary management for pheochromocytoma. However, some patients with pheochromocytoma still suffer from hypertension after successful adrenalectomy. The risk factors for postoperative persistent hypertension remain unclear. Thus the aim of the present study was to identify the risk factors of postoperative persistent hypertension in patients with pheochromocytoma concomitant with hypertension.

METHODS

We retrospectively analyzed 259 patients with pheochromocytoma who underwent adrenalectomy in our hospital between January 1, 2007, and December 31, 2018. Patients' demographics, comorbidities, and perioperative data were recorded. The odds ratio (OR) and 95% confidence interval were measured through binary logistic regression. The cutoff values and the area under the curve (AUC) for continuous risk factors of persistent hypertension after adrenalectomy were calculated through receiver operating characteristic curve analysis.

RESULTS

Of the 259 patients, 40.9% (106/259) patients experienced postoperative persistent hypertension. Three independent risk factors of persistent hypertension in patients with pheochromocytoma after adrenalectomy were found to be older age (OR = 1.16, p = 0.037), longer duration of hypertension (OR = 3.10, p = 0.01), and concomitance with cardiovascular events (yes vs. no, OR = 17.17, p = 0.049). The cutoff value of age and duration of hypertension was 66 years (AUC = 0.741, p < 0.0001) and 27 months (AUC = 0.991, p < 0.0001), respectively.

CONCLUSIONS

Collectively, older age, a longer duration of hypertension, and concomitance with cardiovascular events were independent risk factors of persistent hypertension in patients with pheochromocytoma after adrenalectomy. These findings may help in improving perioperative management and follow-up strategies.

The improvement of postoperative blood pressure and associated factors in patients with hormone-negative adrenal adenoma and hypertension

OBJECTIVE

To investigate the effect of adrenal surgery on blood pressure (BP) improvements in patients with hormone-negative adrenal adenoma (HNA) concomitant with hypertension and analyze associated prognostic factors.

METHODS

We retrospectively reviewed the clinical data of patients with HNA and hypertension and patients with aldosterone-producing adenoma (APA) and hypertension who underwent adrenal surgery at our center between 2019 and 2022. Hypertension outcomes were evaluated in all patients and subjects were divided into three groups according to follow-up BP and the administration of anti-hypertensive agents: a clinical curation group, an improvement group, and a no-improvement group. Logistic regression analysis was performed to predict factors associated with clinical curation in patients with HNA post-surgery.

RESULTS

Of the 182 patients with HNA, clinical curation was achieved in 58 patients (31.9%), improvement in 72 (39.5%), and no improvement in 52 (28.6%). The clinical curation, improvement and no improvement rates in patients with APA were 64.8% (n = 118), 15.9% (n = 29), and 19.2% (n = 35). Multivariate logistic regression analysis indicated that a duration of hypertension ≤6 years and a plasma aldosterone level >160 pg/ml were both independent factors for the clinical curation of hypertension in patients with HNA after adrenal surgery.

CONCLUSION

Adrenal surgery can cure or improve hypertension in most patients with HNA, especially in a short duration of hypertension and high plasma levels of aldosterone.

The Value of Targeting CXCR4 With 68Ga-Pentixafor PET/CT for Subtyping Primary Aldosteronism

CONTEXT

Primary aldosteronism (PA) is one of the leading causes of secondary hypertension, and its diagnostic subtyping consistently presents a clinical challenge.

OBJECTIVE

This study aimed to investigate the potential of 68Ga-Pentixafor positron emission tomography/computed tomography (PET/CT) in PA classification and its applicability in guiding the development of clinical treatment plans by increasing the sample size.

METHODS

We prospectively enrolled 120 patients with either PA or nonfunctional adenoma (NFA) for analysis. All patients underwent 68Ga-Pentixafor PET/CT. Of these, 11 patients underwent adrenal venous sampling (AVS), 77 underwent adrenalectomy, 76 received pathological diagnoses, and 71 underwent immunohistochemical detection of aldosterone synthase (CYP11B2). Immunohistochemistry for C-X-C chemokine receptor 4 (CXCR4) was performed in 62 cases. Follow-up was conducted for all patients.

RESULTS

Among the 120 patients, 66 were diagnosed with aldosterone-producing adenoma (APA), 33 with idiopathic hyperaldosteronism (IHA), and 21 with NFA. For APA patients, the sensitivity, specificity, and accuracy of visual analysis using 68Ga-Pentixafor PET/CT were 92.40%, 94.40%, and 93.33%, respectively. Furthermore, for APA patients with a nodule greater than 1 cm in diameter, when the maximum standard uptake value was 7.3 or greater, the specificity was 100%; and for APA patients with a nodule less than 1 cm in diameter, 68Ga-Pentixafor PET/CT also exhibited high sensitivity. AVS was successfully performed in 5 patients. Among the 5 patients, the concordance rate between the AVS and 68Ga-Pentixafor PET/CT for PA subtyping was 60%. In the 77 patients who underwent adrenalectomy, 61 PET/CT scans displayed positive lesions, all of which benefited from the surgery. Additionally, the concordance rate between 68Ga-Pentixafor PET/CT imaging and CYP11B2 was 81.69%.

CONCLUSION

68Ga-Pentixafor PET/CT is a reliable and noninvasive functional imaging technique that demonstrates high accuracy in classifying PA and provides valuable guidance for clinical treatment decision-making.

Long-term blood pressure outcomes of laparoscopic adrenalectomy in trHTN patients

Background and Objectives

Treatment resistant hypertension (trHTN) is a common clinical problem faced by many clinicians. Laparoscopic adrenalectomy effectively trims blood pressure (BP) elevation secondary to various functional adrenal disorders. However, the impact of adrenalectomy on BP within trHTN patients has never been reported. Our present study aims to investigate the effect of adrenalectomy on BP management within trHTN patients, and to explore clinical predictors for postoperative BP normalization.

Patients and Methods

In our current study, 117 patients diagnosed with trHTN and performed with unilateral adrenalectomy were consecutively enrolled, demographic and medical information were documented for baseline data collection. BP was measured with a standard electronic sphygmomanometer twice a day. Long-term periodical interview was conducted and 109 (93.2%) enrolled patients were successfully followed-up at an averaged 36.2 months.

Results

At follow-up, 27/109 (25%) trHTN patients acquired BP normalization and 68/109 (62%) patients acquired BP improvement. Mean taking anti-hypertensive agents reduced from presurgical 4.24 to present 1.21 (P < 0.01), along with 7.2 mmHg reduction in SBP (P < 0.01). Image macro-adenoma and hypokalemia history were found to be the two strongest predictors for postoperative BP normalization. (χ2= 28.032, P < 0.01). The incidence of adverse postoperative events was quite small.

Conclusions

In summary, this current study implicates that adrenalectomy is an efficacious and safe surgical strategy for BP management in trHTN patients. Patients with both unilateral macro-adenoma and hypokalemia are more prone to acquire postoperative BP normalization.

An 8-year clinical experience with diagnosis and treatment of adrenal lesions with calcification

Adrenal lesions with calcification are uncommon and surgical indication remains controversial. We evaluate rational indications for surgical intervention of adrenal lesions with calcification. From 2013 to 2021, 75 adrenal lesions with calcification managed with surgery had necessary studies for evaluation of rational surgical indication. Clinical benefit was defined as relief of symptoms or/and removal of the malignant tumors. Influencing factors for clinical benefit were evaluated by logistic regression. During the past 8-year period, 5057 patients received adrenal surgery in our center and 75 (1.5%) patients were accompanied with calcification, including 34 males and 41 females with a median age of 54 years (IQR = 41-63 years). The median maximum diameter of calcified adrenal lesions on preoperative CT imaging was 4.2 cm (IQR = 3.0-5.9 cm). Clinical benefit was achieved in 22 cases, including 4 cases of malignant tumors and 18 cases of relieved clinical symptoms. Correlation analysis indicated that maximum diameter of the lesion was significantly correlated with clinical benefit (p = 0.025). The maximum diameter in benefit group vs. non-benefit group was 5.5 cm (IQR = 3.7-7.4 cm) vs. 3.7 cm (IQR = 2.8-5.4 cm). AUC of the maximum diameter ROC curve of adrenal lesions was 0.662. The diameter, sensitivity and specificity corresponding to the maximum Youden index value were 4.5 cm, 0.682 and 0.623, respectively. Clinical benefit was not significantly correlated with calcification distribution (peripheral or internally scattered) (P = 0.106), calcification area ≥ 50% (P = 0.617) and internal enhancement of the lesion (P = 0.720). Adrenal lesions with calcification are mostly benign. Clinical benefit is significantly correlated with the maximum diameter of the lesion and 4.5 cm may be considered as the cutoff point of surgical intervention.

Tailored Approach in Adrenal Surgery: Retroperitoneoscopic Partial Adrenalectomy

The interest on partial adrenalectomy has steadily increased over the past twenty years. Adrenal pathologies are mostly benign, making an organ-preserving procedure attractive for many patients. The introduction of minimally invasive techniques played probably an important role in this process because they transformed a complex surgical procedure, related to the difficult access to the retroperitoneal space, into a simple operation improving the accessibility to this organ. In this review we summarize the role of partial retroperitoneoscopic adrenalectomy over the years and the current indications and technique.

Long-term blood pressure outcomes of laparoscopic adrenalectomy in trHTN patients

Background and Objectives

Treatment resistant hypertension (trHTN) is a common clinical problem faced by many clinicians. Laparoscopic adrenalectomy effectively trims blood pressure (BP) elevation secondary to various functional adrenal disorders. However, the impact of adrenalectomy on BP within trHTN patients has never been reported. Our present study aims to investigate the effect of adrenalectomy on BP management within trHTN patients, and to explore clinical predictors for postoperative BP normalization.

Patients and Methods

In our current study, 117 patients diagnosed with trHTN and performed with unilateral adrenalectomy were consecutively enrolled, demographic and medical information were documented for baseline data collection. BP was measured with a standard electronic sphygmomanometer twice a day. Long-term periodical interview was conducted and 109 (93.2%) enrolled patients were successfully followed-up at an averaged 36.2 months.

Results

At follow-up, 27/109 (25%) trHTN patients acquired BP normalization and 68/109 (62%) patients acquired BP improvement. Mean taking anti-hypertensive agents reduced from presurgical 4.24 to present 1.21 (P = 0.000), along with 7.2 mmHg reduction in SBP (P = 0.000). Image macro-adenoma and hypokalemia history were found to be the two strongest predictors for postoperative BP normalization. (χ2 = 28.032, P = 0.000). The incidence of adverse postoperative events was quite small.

Conclusions

In summary, this current study implicates that adrenalectomy is an efficacious and safe surgical strategy for BP management in trHTN patients. Patients with both unilateral macro-adenoma and hypokalemia are more prone to acquire postoperative BP normalization.

Lateral retroperitoneoscopic adrenalectomy: advantages and drawbacks

Lateral retroperitoneoscopic adrenalectomy (LRA) is performed mostly by urologists. It is gaining popularity among general surgeons because of the direct access to the adrenal gland. However, the management of large tumors remains controversial. We report our experience and discuss the advantages and the drawbacks of this approach. Between December 2011 and April 2015, 89 consecutive patients underwent LRA for adrenal tumors. Conversion to open surgery, operative time, blood loss, hospital stay, intra-operative complications, early and late postoperative complications, and mortality were analyzed. The entire group was divided into patients with large tumors (> 5 cm) and patients with small tumors (≤ 5 cm), which were further compared. The conversion rate was 1.1%. The mean operative time was 107.4 ± 27.95 min, the mean blood loss 33.15 ± 25.45 ml. The mean hospital stay was 4.7 ± 2.05 days. Most of the complications were minor. There was zero mortality. Concerning the size of the tumor, we found statistically significant difference in operative time (p = 0.001), hospital stay (p = 0.020), incidence of early postoperative complications (p = 0.049), and conversion rate to open surgery (p = 0.037). LRA is a feasible, effective and safe procedure that offers additional advantages over the standard transabdominal approach because of its direct access to the adrenal gland. However, malignancy, large tumor size, bilateral pathology, and concomitant intra-abdominal pathology may represent a potential setback for this approach.

Surgical management of large adrenal tumors: impact of different laparoscopic approaches and resection methods on perioperative and long-term outcomes

Background

The indication of retroperitoneal laparoscopic adrenalectomy (RLA) was extended with the retroperitoneal approach and has been wildly accepted and technologically matured. However, the management of large adrenal tumors via this approach still remains controversial. The aim of this study was to perform a comprehensive analysis on the minimally invasive surgical management of larger adrenal tumors.

Methods

A total of 78 patients with large adrenal tumors (> 5 cm) and 97 patients with smaller adrenal tumors (< 5 cm) were enrolled in this study. The patient characteristics were preferentially analyzed. The intra-operative and postoperative indicators were compared between those who underwent RLA and those who underwent transperitoneal laparoscopic adrenalectomy (TLA); the intra-operative and postoperative indicators were also compared between the large tumor group and smaller tumor group of those who underwent RLA. Furthermore, the analyses of partial RLA were focused on the perioperative indicators and follow-up results.

Results

RLA was superior to TLA in terms of operation time (98.71 ± 32.30 min vs. 124.36 ± 34.62 min, respectively, P = 0.001), hospitalization duration (7.43 ± 2.82 days vs. 8.91 ± 3.40 days, respectively, P = 0.04), duration of drain (4.83 ± 0.37 days vs. 3.94 ± 2.21 days, respectively, P = 0.02), first oral intake (2.82 ± 0.71 days vs. 1.90 ± 0.83 days, respectively, P < 0.001) and time to ambulation (3.89 ± 1.64 days vs. 2.61 ± 1.42 days, respectively, P < 0.001). Further analyses of the RLA patients demonstrated that the larger tumor (> 5 cm) group showed superior results for the intraoperative indicators than the smaller tumor (< 5 cm) group (P < 0.05), while the results for the postoperative indicators between the two tumor size groups were similar (P > 0.05). Data confirmed that the partial resection method was superior to the total resection method from the perspective of the hormone supplement (0% vs. 48.15%, P = 0.002). The 2-year recurrence-free rates were 92.60 and 92.86% for the total and partial RLA resection methods, respectively (P = 0.97). The partial RLA resection method had a similar complete remission rate as the total RLA resection method (96.30% vs. 100%, respectively, P = 0.47).

Conclusion

Both RLA and TLA seem to provide similar effects for the surgical management of large adrenal tumors. However, partial RLA resection should be considered for the management of benign tumors to reduce the hormone supplement.

Electronic supplementary material

The online version of this article (10.1186/s12894-018-0349-0) contains supplementary material, which is available to authorized users.