Work-up of the functional adrenal mass

Recurrence Rate of Sporadic Pheochromocytomas After Curative Adrenalectomy: A Systematic Review and Meta-analysis

BACKGROUND

Evidence on follow-up duration for patients with sporadic pheochromocytomas is absent, and current guidelines of the European Society of Endocrinology, American Association of Clinical Endocrinologists and Endocrine Surgeons, and the Endocrine Society are ambiguous about the appropriate duration of follow-up. The aim of this systematic review and meta-analysis is to evaluate the recurrence rate of sporadic pheochromocytomas after curative adrenalectomy.

MATERIALS AND METHODS

A literature search in PubMed, Embase, and the Cochrane Library was performed. A study was eligible if it included a clear report on the number of sporadic patients, recurrence rate, and follow-up duration. Studies with an inclusion period before 1990, <2 years of follow-up, <10 patients, and unclear data on the sporadic nature of pheochromocytomas were excluded. A meta-analysis on recurrence was performed provided that the heterogeneity was low (I2 < 25%) or intermediate (I2 26-75%). Hozo's method was used to calculate weighted mean follow-up duration and weighted time to recurrence with combined standard deviations (SDs).

RESULTS

A total of 13 studies, including 430 patients, were included in the synthesis. The meta-analysis results describe a pooled recurrence rate after curative surgery of 3% (95% confidence interval: 2-6%, I2 = 0%), with a weighted mean time to recurrence of 49.4 months (SD = 30.7) and a weighted mean follow-up period of 77.3 months (SD = 32.2).

CONCLUSIONS

This meta-analysis shows a very low recurrence rate of 3%. Prospective studies, including economical and health effects of limited follow-up strategies for patients with truly sporadic pheochromocytomas should be considered.

The case series of functional adrenal tumors: Experience of two tertiary hospitals in Yaoundé, Cameroon

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This is a case series of functional adrenal tumors and treatment outcomes.

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A diversity of cases is presented with clinical, medical imaging, macroscopic and microscopic features included.

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Successful management of two cases of adrenal insufficiency following classic adrenalectomy in a low resource community is reported.

Introduction

Adrenal tumors are often found incidentally during abdominal imaging. Functioning adrenal tumors are less frequent than these incidentalomas discovered unexpectedly. We report treatment outcomes (major complications) of 7 cases of symptomatic adrenal masses from 2009 to 2019.

Presentation of the cases

Seven cases of functioning adrenal tumors: four adenomas presenting with Cushing’s syndrome, two adrenal carcinomas, and one pheochromocytoma are described. The preoperative diagnoses were made through clinical manifestations, an increase in urinary free cortisol with normal ACTH, elevated metanephrine and enlarged masses on CT. The diagnoses were established on histopathology of adrenalectomy specimens. Adrenal insufficiency in two patients following surgery was corrected with corticoid replacement therapy. One patient died of hypovolemia the day of surgery and another from anaphylactic shock (allergy) late in the post-operative period.

Discussion

Pre, intra and post-operative complications from vascular instability often complicate surgery in functioning adrenal tumors. Adrenal adenomas manifest as Cushing’s syndrome in 10–15 % of patients. They are the most common adrenal tumor although the diagnosis is most often coincidental to abdominal imaging. The incidence of adrenal adenoma increases with age, up to 7 % in the seventh decade. Laparoscopic adrenalectomy, which was not available in our hospitals then, is standard treatment for most tumors. It is alleged to have better outcomes in trained and tested hands.

Conclusion

Surgery of functioning adrenal tumors demands close collaboration of multiple clinical disciplines to manage vascular instability and adrenal insufficiency, especially in resource strapped communities.

Evaluation of Midnight Salivary Cortisol as a Predictor Factor for Common Carotid Arteries Intima Media Thickness in Patients with Clinically Inapparent Adrenal Adenomas

Purpose. The aim of the present study was to investigate the atherosclerotic vascular damage in a consecutive series of patients with AI and to correlate it with MSC. Methods. We studied 32 patients with AI matched with control subjects for age, sex, and cardiovascular risk factors. Either patients or control subjects underwent MSC measurement as outpatients and carotid arteries ultrasound (US) imaging studies. Results. The patients with AI had higher mean carotid artery IMT values and higher MSC levels than control subjects. In a multivariate analysis performed in AI age was the best predictor for IMT. We have stratified patients and control subjects by age (<60 yrs and ≥60 yrs). The patients showed significantly higher MSC levels than controls in both groups, whereas significantly higher IMT values were observed only in older subjects. Conclusions. Patients with AI have signs of accelerated atherosclerosis. Patients older than 60 years seem more susceptible to the possible detrimental effect of subclinical hypercortisolism on cardiovascular system. The MSC levels are not a strong predictor of the accelerated atherosclerosis, but they seem to indicate the subtle but not autonomous cortisol excess that may potentially raise the cardiovascular risk.

Clinical and imaging overview of functional adrenal neoplasms

Adrenal adenoma, adrenocortical carcinoma, pheochromocytoma and neuroblastoma are four discrete adrenal neoplasms that have the potential for functional activity. Functional adrenal neoplasms can secrete cortisol, aldosterone, sex hormones or catecholamines. These heterogeneous groups of tumors show varied biological behavior and clinical outcomes. These neoplasms are encountered with increasing clinical frequency as a result of an expansion in the volume of medical imaging carried out. The clinical presentation, including prognosis and treatment options, and the imaging features of these neoplasms are discussed. The key radiological observations of each of these neoplasms are shown using multimodality images. Familiarity with the clinical and imaging features of these neoplasms improves diagnosis, and facilitates appropriate clinical decision-making and patient management.

Skeletal muscle insulin resistance in endocrine disease

We summarize the existing literature data concerning the involvement of skeletal muscle (SM) in whole body glucose homeostasis and the contribution of SM insulin resistance (IR) to the metabolic derangements observed in several endocrine disorders, including polycystic ovary syndrome (PCOS), adrenal disorders and thyroid function abnormalities. IR in PCOS is associated with a unique postbinding defect in insulin receptor signaling in general and in SM in particular, due to a complex interaction between genetic and environmental factors. Adrenal hormone excess is also associated with disrupted insulin action in peripheral tissues, such as SM. Furthermore, both hyper- and hypothyroidism are thought to be insulin resistant states, due to insulin receptor and postreceptor defects. Further studies are definitely needed in order to unravel the underlying pathogenetic mechanisms. In summary, the principal mechanisms involved in muscle IR in the endocrine diseases reviewed herein include abnormal phosphorylation of insulin signaling proteins, altered muscle fiber composition, reduced transcapillary insulin delivery, decreased glycogen synthesis, and impaired mitochondrial oxidative metabolism.

Clinical and radiological features of adrenal cysts

Adrenal cysts are very rare lesions, usually asymptomatic or without characteristic symptoms. They are classified as pseudocysts, endothelial cysts, epithelial cysts or parasitic cysts. Although pseudocysts are reported to be the most common clinically recognized adrenal cysts in surgical series, endothelial cysts are more common in autopsy series. We studied 15 consecutive patients with adrenal cysts who underwent surgical resection at our institution from 1990 to 2005. Of 15 patients with adrenal cysts, 10 had pseudocysts, 3 epithelial cysts, 1 an endothelial cyst and 1 a parasitic cyst. In conclusion, a better understanding of cystic adrenal masses is necessary to recognize true adrenal cysts and differentiating them from adrenal carcinoma or adenoma by demonstrating the foci of cystic or degenerative changes.

[Adrenal incidentalomas. A disease on the increase]

INTRODUCTION

Adrenal incidentalomas are unsuspected, clinically silent adrenal lesions discovered incidentally by imaging tests performed a priori for problems unrelated to the adrenal glands. The aim of this study was to present a series of incidentalomas and review the diagnostic process and treatment techniques.

PATIENTS AND METHOD

Of a series of 63 patients studied and/or treated for adrenal disease, there were 34 patients with adrenal incidentalomas. The mean age of the patients with incidentaloma was 50.6 years. There were 23 women (67.6%) and 11 men (32.3%). All patients underwent hormonal investigations to rule out hyperfunction. Imaging techniques consisted of ultrasonography, computed tomography (CT) and/or magnetic resonance imaging (MRI) to determine the size and characteristics of the lesion. In patients with an indication for surgery, the lateral transabdominal approach was used in laparoscopic surgery and the anterior approach was used in open surgery.

RESULTS

Of the 34 patients, 23 patients (67.6%) (18 women and 5 men) with a mean age of 50.9 years underwent surgery. The mean tumoral diameter was 10.18 cm. Incidentalomas were located in the right adrenal gland in 16 patients and in the left adrenal gland in 7 patients. Laparoscopic surgery was performed in 9 patients (39.1%) and open surgery was performed in the remaining 14 (60.8%). The mean length of hospital stay was 8.6 days in open surgery and 4 days in laparoscopic surgery. Complications consisted of pneumonia in 2 patients (8.6%). There was no intraoperative mortality in the series. Surgery was not performed in 11 patients (32.3%) (5 women and 6 men) with a mean age of 56.3 years. The mean size of the tumor in these patients, identified by CT, was 2.5 cm. These patients underwent subsequent monitoring with a mean follow-up of 32 months.

CONCLUSIONS

Due to the high resolution of ultrasonography, CT and MRI, as well as the greater number of radiological investigations performed, identification of adrenal incidentalomas has increased. In our series these tumors represented 53.9% of adrenal disease.