Limitations of size as a criterion in the evaluation of adrenal tumors

Simplified urinary steroid profiling by LC-MS as diagnostic tool for malignancy in adrenocortical tumors

OBJECTIVES

Preoperative identification of malignant adrenal tumors is challenging. 24-h urinary steroid profiling by LC-MS/MS and machine learning has demonstrated high diagnostic power, but the unavailability of bioinformatic models for public use has limited its routine application. We here aimed to increase usability with a novel classification model for the differentiation of adrenocortical adenoma(ACA) and adrenocortical carcinoma(ACC).

METHODS

Eleven steroids (5-pregnenetriol, dehydroepiandrosterone, cortisone, cortisol, α-cortolone, tetrahydro-11-deoxycortisol, etiocholanolone, pregnenolone, pregnanetriol, pregnanediol, and 5-pregnenediol) were quantified by LC-MS/MS in 24-h urine samples from 352 patients with adrenal tumor (281 ACA,71 ACC). Random forest modelling and decision tree algorithms were applied in training (n=188) and test sets (n=80) and independently validated in 84 patients with paired 24-h and spot urine.

RESULTS

After examining different models, a decision tree using excretions of only 5-pregnenetriol and tetrahydro-11-deoxycortisol classified three groups with low, intermediate, and high risk for malignancy. 148/217 ACA were classified as being at low, 67 intermediate, and 2 high risk of malignancy. Conversely, none of the ACC demonstrated a low-risk profile leading to a negative predictive value of 100% for malignancy. In the independent validation cohort, the negative predictive value was again 100% in both 24-h urine and spot urine with a positive predictive value of 87.5% and 86.7%, respectively.

CONCLUSIONS

This simplified LC-MS/MS-based classification model using 24-h-urine provided excellent results for exclusion of ACC and can help to avoid unnecessary surgeries. Analysis of spot urine led to similarly satisfactory results suggesting that cumbersome 24-h urine collection might be dispensable after future validation.

Analysis of adrenalectomy for the treatment of adrenal diseases performed by the Public Health Service in São Paulo between 2008 and 2019

INTRODUCTION

treating benign (hormonally active or nonfunctional) and malignant adrenal cancer includes adrenalectomy. The expertise of surgeons and surgery performed by high-volume surgeons were associated with fewer complications and lower cost. We aimed to describe and compare the number of surgeries, mortality rate, and length of hospital stay for adrenalectomies performed between 2008 and 2019 in the public health system of São Paulo.

METHODS

this was an ecological study. The data were collected using the TabNet Platform of the Unified Health System Department of Informatics. Outcomes analyzed included the number of surgeries performed, mortality rate during hospital stay, and length of hospital stay. Public hospitals in Sao Paulo were divided into three subgroups according to the surgical volume of adrenalectomies performed as well as hospitals with and without a residency program in Urology, and the results were compared among them.

RESULTS

a total of 943 adrenalectomies were performed in Sao Paulo between 2008 and 2019. Mortality rates during hospital stay according to hospital surgical volume were no reported deaths in low-volume, 0.015% in intermediate-volume, and 0.004% in high-volume hospitals. The average length of the ICU stay was 1.03 days in low-volume, 2.8 in intermediate-volume, and 1.12 in high-volume hospitals (analysis between intermediate and high volume centers with statistical significance, p=0.016).

CONCLUSIONS

despite no statistically significant differences among the groups analyzed, mortality rates were very low in all groups. ICU stay was shorter in high-volume centers than in intermediate-volume centers.

Análise da adrenalectomia para tratamento de doenças adrenais realizadas pelo Serviço Público de Saúde de São Paulo entre 2008 e 2019

RESUMO Introdução: o tratamento do câncer de adrenal benigno (hormonalmente ativo ou não funcional) e maligno inclui a adrenalectomia. A experiência dos cirurgiões e a cirurgia realizada por cirurgiões de alto volume foram associadas a menos complicações e menor custo. O objetivo do estudo foi descrever e comparar o número de cirurgias, a taxa de mortalidade e o tempo de internação para adrenalectomias realizadas entre 2008 e 2019 na rede pública de saúde de São Paulo. Métodos: trata-se de um estudo ecológico. Os dados foram coletados da Plataforma TabNet do Departamento de Informática do Sistema Único de Saúde. Os hospitais foram divididos em três subgrupos de acordo com o volume cirúrgico e hospitais com e sem programa de residência médica em Urologia. Os resultados foram comparados entre os grupos. Resultados: no período estudado, 943 adrenalectomias foram realizadas em São Paulo. As taxas de mortalidade durante a internação de acordo com o volume cirúrgico hospitalar foram: não foram relatados óbitos em hospitais de baixo volume; 0,015% em hospitais de volume intermediário e 0,004% em alto volume. O tempo médio de permanência na UTI foi de 1,03 dias nos hospitais de baixo volume; 2,8 nos de médio volume e 1,12 nos de alto volume (análise entre centros de médio e alto volume com significância estatística, p=0,016). Conclusão: as taxas de mortalidade foram muito baixas em todos os grupos. A permanência na UTI foi menor em centros de alto volume do que em centros de volume intermediário.

Large Adrenal Lesion Series in a Tertiary Care Center in Northern India: Diagnostic and Operative Challenges

Large adrenal tumors pose varied challenges to surgeons in terms of diagnosis, planning surgical approach, and also intra-operative difficulties in resection. The aim of this study is to discuss challenges in the management of large and difficult adrenal lesions. A retrospective analysis was done on data of all patients with large adrenal lesions/paragangliomas managed from 1 June 2016 to 30 August 2018. Forty-eight patients with adrenal lesions underwent treatment in 2 years duration. Pain in the abdomen was the most common presentation. Mean age was 34.4 years (range 2-60), female to male (23:25) and right to left side to bilateral tumor 30:16:2. Thirty-one (64.6%) patients had large adrenal masses (size > 6 cm). Surgical approaches included open transperitoneal adrenalectomy (n = 20) and laparoscopic transperitoneal (n = 9 and 2 others had conversion to open procedure). Challenges faced are described in the table below: [Table: see text] There were no major peri-operative morbidities, but two patients died in perioperative period. Large adrenal tumors pose a challenge in surgical planning, approach, and resection and need careful planning and multidisciplinary team approach to have the best outcomes.

Mimics, pitfalls, and misdiagnoses of adrenal masses on CT and MRI

Due to the widespread use of imaging, incidental adrenal masses are commonly encountered. A number of pitfalls can result in misdiagnosis of these lesions, including inappropriate choice of imaging technique, presence of pseudolesions, and overlap of imaging features of different adrenal lesions. This article explores the potential pitfalls in imaging of the adrenal glands, on computed tomography and magnetic resonance imaging, that can lead to misinterpretation. Clues to correct diagnoses are provided to evade potential misinterpretation.

Association between Tumor Size and Malignancy Risk in Hormonally Inactive Adrenal Incidentalomas

Introduction

Adrenal incidentalomas (AI) are adrenal masses that are discovered during radiological examinations conducted for other reasons. In this study, we focused on the pathological and radiological properties of nonfunctional AI(NFAI) and the association with malignancy risk in our clinical series.

Methods

A total of 186 patients underwent adrenalectomy between 2010 and 2017; of these, 76 (40.8%) patients with non-functional AI were included in the current study. The radiological and pathologic characteristics of these AIs were retrospectively analyzed to determine the malignancy rate.

Results

There were 22 (28.9%) male and 54 (71.1%) female patients with nonfunctional AI included in this study. The median age was 55 (range: 24-85) years. Of the patients included, 37 (48.6%) had AI on the left and 39 (51.3%) had AI on the right adrenal gland. Sixty-one (80.2%) cases were treated laparoscopically, four (5.3%) required conversion to open surgery due to intraoperative difficulties such as bleeding and adhesions, and 11 (14.4%) were managed with open adrenalectomy. The rate of malignancy in the tumors with diameters of <4 cm, 4-6 cm, and >6 cm was found to be 0%, 2.9%, and 13.6%, respectively.

Conclusions

Determining the ideal cutoff value for surgical indication in an NFAI is challenging. Besides the malignancy risk, the rate of silent pheochromacytomas must be taken into account in the surgical decision.

Metallothionein protein and minichromosome maintenance protein-2 expression in adrenocortical tumors

AIM

Some resected adrenal-confined adrenocortical carcinomas metastasize and others not. The present study was designed to evaluate the expression of metallothionein protein (MT) and minichromosome maintenance protein-2 (MCM2) in adrenocortical carcinomas and adrenocortical adenomas, and to test the correlation between this and adrenocortical carcinoma aggressiveness.

MATERIALS AND METHODS

The study comprised 14 patients operated on for adrenocortical carcinoma, 15 operated on for adrenocortical adenoma and 2 with normal adrenals. Hematoxylin-eosin staining was used for histological evaluation under light microscopy, and sequential sections were used for MCM2 and MT staining.

RESULTS

In normal adrenals, positive staining was weak for MT and zero for MCM2. Rates of positive staining for MT and MCM2 were significantly higher in adrenocortical carcinomas than in adrenocortical adenomas (P=0.008 and P<0.001, respectively). In adrenocortical carcinomas, a significant positive correlation was found between MCM2 staining and Weiss revisited score (P=0.022) but not for Weiss score, and a significant positive correlation was found between MCM2 and mitotic rate on histology (P=0.033). MCM2 but not MT staining was also shown to correlate significantly with stage IV carcinoma (P=0.008 and P=0.165, respectively).

CONCLUSION

MCM2 and MT are overexpressed in adrenocortical carcinoma, and MCM2 expression correlates significantly with metastatic disease.

Adrenocortical carcinoma: presentation and outcome of a contemporary patient series

BACKGROUND

Adrenocortical carcinoma (ACC) is a rare endocrine carcinoma with poor 5-year survival rates of < 40%. According to the literature, ACC is rarely an incidental imaging finding. However, presentation, treatment and outcome may differ in modern series.

DESIGN AND METHODS

We studied all patients (n = 47, four children) from a single centre during years 2002-2018. We re-evaluated radiologic and histopathological findings and assessed treatments and outcome. We searched for possible TP53 gene defects and assessed nationwide incidence of ACC.

RESULTS

In adults, incidental radiologic finding led to diagnosis in 79% at median age of 61 years. ENSAT stage I, II, III and IV was 19%, 40%, 19% and 21%, respectively. Nonenhanced CT demonstrated > 20 Hounsfield Units (HU) for all tumours (median 34 (21-45)), median size 92 mm (20-196), Ki67 17% (1-40%), Weiss score 7 (4-9) and Helsinki score 24 (4-48). ACC was more often found in the left than the right adrenal (p < 0.05). One child had Beckwith-Wiedemann and one a TP53 mutation. In adults, the primary tumour was resected in 88 and 79% received adjuvant mitotane therapy. Median hospital stay was significantly shorter in the laparoscopic vs. open surgery group (4 (3-7) vs. 8 (5-38) days, respectively; p < 0.001). In 3/4 patients, prolonged remission of > 5 to > 10 years was achieved after repeated surgery of metastases. Overall 5-year survival was 67%, and 96% vs. 26% for ENSAT stage I-II vs. III-IV (p < 0.0001). ENSAT stage and Ki67 predicted survival, type of surgery did not. Mitotane associated with better survival.

CONCLUSIONS

Contemporary ACC predominantly presents as an incidental imaging finding, characterised by HU > 20 on nonenhanced CT but variable tumour size (20-196 mm). Malignancy cannot be ruled out by small tumour size only. The 5-year survival of 96% in ENSAT stage I-III compares favourably to previous studies.

Adrenocortical neoplasms in adulthood and childhood: distinct presentation. Review of the clinical, pathological and imaging characteristics

Adrenocortical tumors (ACT) in adulthood and childhood vary in clinical, histopathological, molecular, prognostic, and imaging aspects. ACT are relatively common in adults, as adenomas are often found incidentally on imaging. ACT are rare in children, though they have a significantly higher prevalence in the south and southeast regions of Brazil. In clinical manifestation, adults with ACT present more frequently with glucocorticoid overproduction (Cushing syndrome), mineralocorticoid syndromes (Conn syndrome), or the excess of androgens in women. Subclinical tumors are frequently diagnosed late, associated with compression symptoms of abdominal mass. In children, the usual presentation is the virilizing syndrome or virilizing association and hypercortisolism. Histopathological grading and ACT classification in malignant and benign lesions are different for adults and children. In adults, the described criteria are the Hough, Weiss, modified Weiss, and Van Slooten. These scores are not valid for children; there are other criteria, such as proposed by Wieneke and colleagues. In molecular terms, there is also a difference related to genetic alterations found in these two populations. This review discusses the imaging findings of ACT, aiming to characterize the present differences between ACT found in adults and children. We listed several differences between magnetic resonance imaging (MRI), computed tomography (CT), and positron emission tomography-computed (PET-CT) and also performed a literature review, which focuses on studied age groups of published articles in the last 10 years regarding cortical neoplasm and imaging techniques. Published studies on ACT imaging in children are rare. It is important to stress that the majority of publications related to the differentiation of malignant and benign tumors are based almost exclusively on studies in adults. A minority of articles, however, studied adults and children together, which may not be appropriate.

Management of Adrenal Masses

An adrenal mass can be either symptomatic or asymptomatic in the form of adrenal incidentalomas (AIs) in up to 8 % in autopsy and 4 % in imaging series. Once a diagnosis of adrenal mass is made, we need to differentiate whether it is functioning or nonfunctioning, benign, or malignant. In this article, we provide a literature review of the diagnostic workup including biochemical evaluation and imaging characteristics of the different pathologies. We also discuss the surgical strategies with laparoscopy as the mainstay with partial adrenalectomy in select cases and adrenalectomy in large masses. Follow-up protocol of AIs and adrenocortical carcinoma is also discussed.

Laparoscopic Transperitoneal Lateral Adrenalectomy for Large Adrenal Tumors

BACKGROUND

Laparoscopic adrenalectomy is the gold standard for treatment of benign adrenal lesions. Tumor size is a factor that might influence decision-making concerning the use of laparoscopic approach. The aim of this study was to analyze the results of adrenalectomy for tumors ≥6 cm in diameter.

METHODS

Two groups of patients were analyzed: first group comprised 441 patients with tumors <6 cm in diameter and second group consisted of 89 patients with tumors ≥6 cm. Both groups were compared with regard to the duration of surgery, intraoperative blood loss, conversion and complications rate.

RESULTS

Median duration of surgery in groups 1 and 2 amounted to 86.6 and 111.9 min (p < 0.0001), respectively. Median intraoperative blood loss in groups 1 and 2 was 56.5 and 172.8 ml (p < 0.0001), respectively. There was a linear relationship between tumor size and the duration of surgery, and between tumor size and intraoperative blood loss (p < 0.0001). There were 2 (0.5%) and 6 (6.7%) conversions in groups 1 and 2, respectively. There were 41 (9.3%) and 14 (15.7%) complications in groups 1 and 2 (p = 0.0692), respectively.

CONCLUSIONS

Laparoscopic adrenalectomy of tumors ≥6 cm is more difficult, but it can be regarded safe and beneficial for patients.

Preexisting adrenal masses in patients with adrenocortical carcinoma: clinical and radiological factors contributing to delayed diagnosis

Adrenocortical carcinoma (ACC) is a rare endocrine malignancy that is usually large (>5 cm) at time of diagnosis. Delayed diagnosis significantly worsens survival. We describe adrenal gland morphology prior to ACC diagnosis and discern potential causes of delayed diagnosis. ACC patients seen at The University of Texas MD Anderson Cancer Center between 1998 and 2014 who had cross-sectional body imaging ≥3 months prior to their diagnosis. We conducted a detailed review of clinical and radiological features in these patients prior to ACC diagnosis. Of 439 patients with ACC, 25 had imaging preceding ACC diagnosis (5 with normal adrenal glands and 20 with preexisting masses). On the first available images, the median mass size was 2.8 cm (range 0-9) with median precontrast density of 36 Hounsfield units (range 17-43) and became 9 cm (range 1-18) at the time of ACC diagnosis. The median interval between first available image and ACC diagnosis was 20 months (range 3-89). In the 5 patients whose initial images showed normal adrenal glands, the time between the last normal scan and ACC diagnosis ranged from 5 to 36 months. The most common reason for delayed ACC diagnosis was the presumed benign status of the preexisting mass (n = 13, 65 %). Radiologically suspicious adrenal masses can precede ACC diagnosis and have variable growth patterns. ACC can also develop de novo within a few months in a radiologically documented normal adrenal gland. The presumed benignancy of preexisting masses based on size is the main reason for delayed ACC diagnosis.

Applicability of laparoscopic approach to the resection of large adrenal tumours: a retrospective cohort study on 200 patients

BACKGROUND

Controversies exist in the best surgical approach (open vs. laparoscopy) to large adrenal tumours without peri-operative evidence of primary carcinoma, mainly due to possible capsular disruption of an unsuspected malignancy. In addition, intra-operative blood loss, conversion rate, operative time, and hospital stay may be increased with laparoscopy.

THE AIMS OF OUR STUDY WERE

(1) to compare clinical outcomes of laparoscopic adrenalectomy for large versus small adrenal tumours and (2) to identify risk factors associated with increased operative time and hospital stay in laparoscopic adrenalectomy.

METHODS

This is a multicentre retrospective cohort study in a large patient population (N = 200) who underwent laparoscopic adrenalectomy in 2004-2014 at three Italian academic hospitals. Patients were divided into two cohorts according to tumour size: "large" tumours were defined as ≥5 cm (N = 50) and "small" tumours as <5 cm (N = 150). Further analysis adopting a ≥8 cm (N = 15) cut-off size was performed.

RESULTS

The study groups were comparable in age and gender distribution as well as their tumour characteristics. The operative time (p = 0.671), conversion rate (p = 0.488), intra- (p = 0.876) and post-operative (p = 0.639) complications, and hospital stay (p = 0.229) were similar between groups. With a cut-off size ≥5 cm, the early study period (2004-2009), which included operators' learning curve, was associated with increased risk of longer operative time (HR 0.57; 95 % CI 0.40-0.82), while American Society of Anaesthesiology score ≥3 was associated with prolonged hospital stay (HR 0.67; 95 % CI 0.47-0.97). Tumour size ≥8 cm was associated with prolonged operative time (HR 0.47; 95 % CI 0.24-0.94).

CONCLUSIONS

Surgeons skilled in advanced laparoscopy and adrenal surgery can perform laparoscopic adrenalectomy safely in patients with ≥5-cm tumours with no increase in hospital stay, or conversion rate, although operative time may be increased for ≥8-cm tumours. Surgeon' experience, size ≥8 cm, and patient comorbidities have the largest impact on operative time and length of hospital stay in laparoscopic large adrenal tumour resection.

Surgical treatment of potentially primary malignant adrenal tumors: an unresolved issue

Although the great majority of incidentalomas are adrenocortical adenomas, a number of them, depending on the size and radiological characteristics of the lesions, will turn out to be carcinomas. These tumors may present as suspicious on initial evaluation and potentially malignant or malignant on histology. Adrenocortical carcinoma is a rare and aggressive malignancy with evolving diagnostic and therapeutic approaches. Laparoscopic surgery has become the gold standard for surgery of benign adrenal tumors. Despite the extensive experience gained in laparoscopic adrenalectomy, controversy still remains in the management of adrenal tumors with high suspicion or evidence of malignancy. The aim of this review is to update the existing information regarding the diagnostic approach and surgical management of suspicious and potentially malignant primary adrenal tumors.The interpretation of radiologic characteristics is a cornerstone in pre-operative assessment of large adrenal masses, since open surgery remains the preferred procedure when malignancy is suspected in large tumors with possible local invasion. Despite the improvement of imaging techniques, they lack sufficient accuracy to exclude primary malignancy in tumors from 4 cm to 10 cm in size. An initial laparoscopic approach can be used in this group of patients, but early conversion to open technique is mandatory if curative resection cannot be performed. Adrenal tumors >10 cm of malignant potential should be treated by the open approach from the start. Solitary adrenal metastasis from another primary malignancy is usually amenable to laparoscopic surgery. Patients with suspected adrenal cancer should be referred to tertiary centers that perform laparoscopic and open adrenal surgery with minimal morbidity and mortality.

Adrenal incidentalomas: should we operate on small tumors in the era of laparoscopy?

Tumor size smaller than 4 cm as an indication for surgical treatment of incidentaloma is still a subject of discussion. Our aim was the estimation of the incidence of malignancy and analysis of treatment outcomes in patients with incidentaloma smaller than 4 cm in comparison to bigger lesions. 132 patients who underwent laparoscopic adrenalectomy for nonsecreting tumors were divided into two groups: group 1 (55 pts., size < = 40 mm) and group 2 (77 pts., size > 40 mm). Operation parameters and histopathological results were analyzed. No differences in group characteristics, mean operation time, and estimated blood loss were noted. Complications in groups 1 and 2 occurred in 3.6% and 5.2% of patients, respectively (P = 0.67). Malignancy in groups 1 and 2 was present in 1 and 6 patients, respectively (P = 0.13). Potentially malignant lesions were identified in 4 patients in group 1 and 4 patients in group 2 (P = 0.39). The results do not allow for straightforward recommendations for surgical treatment of smaller adrenal tumors. The safety of laparoscopy and minimal, but impossible to omit, risk of malignancy support decisions for surgery. On the other hand, the risk of malignancy in smaller adrenal tumors is lower than surgical complications, which provides an important argument against surgery.

Does laparoscopic adrenalectomy jeopardize oncologic outcomes for patients with adrenocortical carcinoma?

BACKGROUND

For patients with known or suspected adrenocortical carcinoma (ACC), considerable controversy exists over the use of laparoscopic adrenalectomy. The purpose of this study was to assess recurrence and survival patterns in patients with a pathologic diagnosis of ACC treated with laparoscopic versus open adrenalectomy.

METHODS

All patients referred to our center with a diagnosis of ACC from April 1, 1993 to May 1, 2012 were reviewed. Three groups of patients were compared: patients referred after laparoscopic resection elsewhere, patients referred after open resection elsewhere, and patients treated primarily at our center (all resected by the open approach). Clinical factors and overall, recurrence-free, and peritoneal recurrence-free survivals were compared between groups.

RESULTS

During the study period, 46 patients presented after laparoscopic resection at an outside institution, 210 patients after open resection at an outside institution, and 46 patients were treated at our institution with open resection. Despite a smaller tumor size, patients treated laparoscopically developed peritoneal carcinomatosis more frequently compared to those treated with an open approach (p = 0.006 for number with peritoneal recurrence). When controlling for tumor stage, open-approach patients experienced superior recurrence-free and overall survival.

CONCLUSION

Despite typically being performed in patients with smaller tumors, laparoscopic adrenalectomy for ACC is associated with higher rates of recurrence, particularly peritoneal recurrence. For patients with known or suspected ACC, the oncologic benefits of open resection outweigh the short-term benefits of minimally invasive surgery.

A cost-effectiveness analysis of adrenalectomy for nonfunctional adrenal incidentalomas: is there a size threshold for resection?

BACKGROUND

Adrenocortical carcinoma (ACC) is a rare, but aggressive, malignancy. Current American Association of Clinical Endocrinologists (AACE)/American Association of Endocrine Surgeons (AAES) guidelines recommend resection of nonfunctional adrenal neoplasms ≥ 4 cm. This study evaluates the cost-effectiveness of this approach.

METHODS

A decision tree was constructed for patients with a nonfunctional, 4-cm adrenal incidentaloma with no radiographic suspicion for ACC. Patients were randomized to adrenalectomy, surveillance per AACE/AAES guidelines, or no follow-up ("sign-off"). Incremental cost-effectiveness ratio (ICER) includes health care costs, including missed ACC. ICER (dollar/life-year-saved [LYS]) was determined from the societal perspective. Sensitivity analyses were performed.

RESULTS

In the base-case analysis, assuming a 2.0% probability of ACC for a 4-cm tumor, surgery was more cost-effective than surveillance (ICER $25,843/LYS). Both surgery and surveillance were incrementally more cost-effective than sign-off ($35/LYS and $8/LYS, respectively). Sensitivity analysis demonstrated that the model was sensitive to patient age, tumor size, probability of ACC, mortality of ACC, and cost of hospitalization. The results of the model were stable across different cost and complications related to adrenalectomy, regardless of operative approach.

CONCLUSION

In our model, adrenalectomy was cost-effective for neoplasms >4 cm and in patients <65 years, primarily owing to the aggressiveness of ACC. Current AACE/AAES guideline recommendations for the resection of adrenal incidentalomas ≥ 4 cm seem to be cost-effective.

Laparoscopic resection of large adrenal tumors

Results of this study suggest that laparoscopic adrenalectomy should be the treatment of choice for benign adrenal tumors. However, experience in advanced laparoscopic and open abdominal surgery is necessary in the management of large adrenal tumors.

Background:

Laparoscopic adrenalectomy has rapidly replaced open adrenalectomy as the procedure of choice for benign adrenal tumors. It still remains to be clarified whether the laparoscopic resection of large (≥8cm) or potentially malignant tumors is appropriate or not due to technical difficulties and concern about local recurrence. The aim of this study was to evaluate the short- and long-term outcome of 174 consecutive laparoscopic and open adrenalectomies performed in our surgical unit.

Methods:

Our data come from a retrospective analysis of 174 consecutive adrenalectomies performed on 166 patients from May 1997 to December 2008. Fifteen patients with tumors ≥8cm underwent laparoscopic adrenalectomy. Sixty-five patients were men and 101 were women, aged 16 years to 80 years. Nine patients underwent either synchronous or metachronous bilateral adrenalectomy. Tumor size ranged from 3.2cm to 27cm. The largest laparoscopically excised tumors were a ganglioneuroma with a mean diameter of 13cm and a myelolipoma of 14cm.

Results:

In 135 patients, a laparoscopic procedure was completed successfully, whereas in 14 patients the laparoscopic procedure was converted to open. Seventeen patients were treated with an open approach from the start. There were no conversions in the group of patients with tumors >8cm. Operative time for laparoscopic adrenalectomies ranged from 65 minutes to 240 minutes. In the large adrenal tumor group, operative time for laparoscopic resection ranged from 150 minutes to 240 minutes. The postoperative hospital stay for laparoscopic adrenalectomy ranged from 1 day to 2 days (mean, 1.5) and from 5 days to 20 days for patients undergoing the open or converted procedure. The mean postoperative stay was 2 days for the group with large tumors resected by laparoscopy.

Conclusion:

Laparoscopic resection of large (≥8cm) adrenal tumors is feasible and safe. Short- and long-term results did not differ in the 2 groups.

What are the hallmarks of cancer?

The seminal article by Douglas Hanahan and Robert Weinberg on the hallmarks of cancer is 10 years old this year and its contribution to how we see cancer has been substantial. But, in embracing this view, have we lost sight of what makes cancer cancer?

Retrospective evaluation of the outcome of open versus laparoscopic adrenalectomy for stage I and II adrenocortical cancer

BACKGROUND

Although there is consensus that laparoscopy is the standard of care for the resection of benign adrenal tumours, there is controversy regarding the role of laparoscopy for the resection of adrenocortical cancer (ACC).

OBJECTIVE

The aim of the present study was to review the ACC database of the San Luigi Hospital to compare the oncologic effectiveness of open adrenalectomy (OA) versus laparoscopic adrenalectomy (LA) in the treatment of patients with stage I and II ACC.

DESIGN, SETTING, AND PARTICIPANTS

We performed a retrospective analysis involving 43 patients with stage I and II ACC who had undergone radical surgery.

INTERVENTION

The patients were stratified into two groups according to the surgical procedure. The "open group" consisted of patients treated with OA; the "lap group" consisted of patients treated with LA.

MEASUREMENTS

Oncologic effectiveness of the procedures was tested comparing the recurrence-free survival of patients treated with OA versus LA. Secondary outcome measures were differences in terms of type of recurrence and overall survival.

RESULTS AND LIMITATIONS

The open group consisted of 25 patients and the lap group of 18 patients. The two groups were comparable in terms of demographic data. The median follow-up was 38 mo in the open group and 30 mo in the lap group. Recurrence rate was 64% in the open group and 50% in the lap group. The median recurrence-free survival was 18 mo in the open group and 23 in the lap group (p=0.8). No differences in terms of pattern of recurrences were recorded. During follow-up, 28% of the open group patients and 5% of the lap group patients died. No differences in terms of survival time were noted (p=0.3).

CONCLUSIONS

The present findings provide interesting evidence that OA and LA may be comparable in terms of recurrence-free survival for patients with stage I and II ACC when the principles of surgical oncology are respected.

Whether adrenal mass more than 5 cm can pose problem in laparoscopic adrenalectomy? An evaluation of 22 patients

OBJECTIVES

To evaluate technical feasibility and analyze outcome of laparoscopic adrenalectomy (LA) for large adrenal masses more than 5 cm.

METHODS

The data of 22 patients (8 men, 14 women), who underwent LA for adrenal masses >5 cm between January 1995 and July 2007 were analyzed for this study.

RESULTS

Twenty-two patients with a mean age of 42.5 years underwent LA for large adrenal masses (>5 cm) between January 1995 and July 2007. Transperitoneal and retroperitoneal laparoscopic adrenalectomy (TPLA and RPLA) was performed in 15 and 7 patients, respectively. The mean-operative time, blood loss, tumor size and hospital stay were 149.33 and 132.1 min, 132.33 and 94.28 ml, 7.85 and 5.85 cm and 3.5 and 3.28 days, respectively. Histopathological examination of the specimen confirmed adrenal carcinoma in 5, pheochromocytoma in 14, myelolipoma in 2 and adenoma in 1 patient. Two patients of pheochromocytoma had required open conversion, one from each group (TPLA and RPLA). Three patients had postoperative complications (wound infection 1, pneumonitis with fever 1 and retroperitoneal collection 1).

CONCLUSIONS

The size of an adrenal mass on preoperative imaging studies alone should not be the primary factor in determining whether LA should be performed. LA for adrenocortical cancers could be performed safely and effectively in the selected group. Transperitoneal approach is most suitable and recommended for large adrenal tumor and adrenal carcinoma to employ laparoscopy. One approach (TP or RP) over the other also does not lead to the substantial benefits either to the patients or to the surgeon.

Response to mitotane predicts outcome in patients with recurrent adrenal cortical carcinoma

BACKGROUND

Adrenal cortical carcinoma (ACC) is a rare disease in which recurrence after surgery is common. Mitotane is the primary systemic treatment for recurrent ACC; data are limited regarding the impact of mitotane on recurrent ACC.

METHODS

We reviewed the records of all patients who underwent surgery for ACC evaluated at our institution from 1991 to 2006.

RESULTS

The median disease-free survival for all 186 patients was 12 months and the median overall survival (OS) was 37 months. Higher stage at presentation (P = .002) and tumor cortisol production (P = .007) were associated with a worse OS. Mitotane was given to 67 evaluable patients with recurrent ACC. A response to mitotane was observed in 13 (19%) of the 67 patients. For patients with stable or responding disease to mitotane, the median OS from date of recurrence was 18 months, compared with 9 months (P = .01) for those who progressed.

CONCLUSIONS

Patients with recurrent ACC who have stable or responding disease to mitotane have a more favorable prognosis than those who progress. Mitotane should be considered in most patients with recurrent ACC, including as preoperative therapy for those with recurrent disease considered for surgical resection.

Diagnostic challenges in adrenocortical carcinoma: recommendations for surveillance after surgical resection of selected adrenal nodules

OBJECTIVE

To discuss challenges in the diagnosis of adrenocortical carcinoma and to suggest surveillance measures after removal of selected adrenal nodules.

METHODS

We present the case of a 65-year-old man with worsening hypertension and new-onset hypokalemia attributed to primary hyperaldosteronism due to a 3-cm right adrenal nodule.

RESULTS

A laparoscopic right adrenalectomy was performed, and the histologic diagnosis was a benign adenoma. The patient's hypertension and hypokalemia improved postoperatively but recurred 8 months later, and florid Cushing's syndrome developed. Magnetic resonance imaging showed an 8-cm mass in the right adrenal bed and multiple hepatic metastatic lesions. Fine-needle biopsy confirmed the presence of adrenocortical carcinoma.

CONCLUSION

Despite a comprehensive biochemical, radiologic, and histologic assessment, the diagnosis of adrenocortical carcinoma can be missed. Particularly, we caution against undue reliance on the initial tumor size. We recommend that abdominal imaging be performed every 3 months for the first year and every 6 months for the second year after surgical removal of selected adrenal nodules.

Outcomes of laparoscopic adrenalectomy. Clinical experience with 68 patients

The aim of this study was to analyze feasibility and outcomes of laparoscopic adrenalectomy (LA). Pathology, size and bilateral site of lesions were considered. Between December 1998 and May 2007 in our institution a total of 68 patients of mean age of 53 years underwent unilateral (n=57) or bilateral (n=11) LA. Adrenal masses averaged 5.4cm in size (range 1.2-13cm) and 56.7g in weight (range 10-265) including 71 benign and 8 malignant lesions. A total of 79 adrenal glands were resected, 44 right sided and 35 left sided. Removal was complete in 77 cases and partial (sparing adrenalectomy) in 1 patient affected by bilateral pheochomocytoma. Three left adrenalectomies for pheochromocytoma were robot-assisted. The transperitoneal lateral approach was preferred and the posterior retroperitoneal approach was adopted in 5 patients. The mean duration of surgery for each LA was 138+/-90min and 3.8 trocar were used on average (range 3-6). Conversion was needed in 3 cases owing to difficult dissection of large masses. Estimated mean blood loss for each LA was 95+/-30ml and it was greater for bilateral LA. Mortality was nil and morbidity was 5.8%. The average length of hospital stay (LOS) in surgical unit was 4+/-2.4 days (range 2-8). Patients affected by hormone secreting or bilateral lesions, by unilateral or bilateral pheochromocytoma and by bilateral Cushing's disease were transferred to the endocrinological ward so that their overall hospital stay was prolonged to 9+/-2.8 days on average (range 7-17). Mean duration of follow-up of patients was 38 months (range 2-100) and demonstrated acceptable endocrine results. Three primary cortical carcinomas were discovered as chance findings on histologic examination. While long-term results after LA for cortical carcinomas were poor and LA is not recommended in such cases, long-term results after LA for adrenal metastases were encouraging.

Laparoscopic adrenalectomy for suspected metastasis of adrenal glands: our experience

OBJECTIVES

To present our experience in laparoscopic adrenalectomy for isolated adrenal metastasis.

METHODS

A total of 34 adrenalectomies were performed in 32 patients for incidental adrenal masses discovered at primary tumor diagnosis or during follow-up. The primary tumors diagnosed were 13 cases of lung carcinoma, 9 of renal cell carcinoma, 2 of colorectal carcinoma, 2 of bladder carcinoma, and 1 each of ovarian carcinoma, breast cancer, gastric cancer, and melanoma. Two patients had no history of a primary tumor. The mean patient age was 59 years (range 26 to 75). The male/female ratio was 1.9:1.

RESULTS

The mean operative time was 87 minutes (range 40 to 240). The average blood loss was 89 mL (range 0 to 1000). No conversions to open surgery were needed. The mean hospital stay was 3 days (range 1 to 5). One intraoperative diaphragmatic lesion developed that was repaired laparoscopically, and 1 patient had a pancreatic fistula that was managed by percutaneous drainage. The mean tumor size was 4.3 cm (range 1.5 to 9). The microscopic analysis revealed 22 malign lesions (64.7%) and 12 cases of benign pathologic features (35.3%). The mean survival time was 26 months (range 4 to 64) for the 22 patients with malign lesions. In 2 patients (9.1%), the surgical margins were positive.

CONCLUSIONS

Laparoscopic adrenalectomy for small isolated metastases is feasible. However, because of the high risk of positive margins, this procedure should only be done by expert laparoscopists. We did not find a correlation between mass size and malignancy. Nevertheless, we believe that longer follow-up is mandatory before definitive conclusions can be drawn.

Isolated Adrenal Mass in Patients with a History of Cancer: Remember Pheochromocytoma

BACKGROUND

In a patient with a history of cancer, an isolated adrenal mass is usually thought to be a metastasis. Although a biochemical work-up to rule out pheochromocytoma is recommended, some question its practicality. This study was undertaken to determine the incidence of functional adrenal lesions in patients with a history of cancer and examine predictive factors for the type of lesion.

METHODS

At a single institution, 33 patients with an isolated adrenal mass and a history of cancer underwent surgical treatment. Patients' records were retrospectively analyzed for type of adrenal lesion and other diagnostic parameters.

RESULTS

There were 20 males and 13 females with a mean age of 58+/-2 years. Of these, 20 (61%) had adrenal metastases, 8 (24%) had pheochromocytomas, and 5 (15%) had adrenal adenomas. Usual diagnostic criteria, including presenting symptoms, primary tumor, and other demographic characteristics, did not consistently predict the pathology of the lesion.

CONCLUSIONS

Nearly 1 in 4 resected adrenal masses in patients with a history of cancer were pheochromocytomas. The high incidence of pheochromocytoma in this series supports a thorough work-up, irrespective of previous cancer. Therefore, remember one thing in patients with an isolated adrenal mass and a history of cancer: pheochromocytoma.

Long-term outcome following laparoscopic adrenalectomy for large solid adrenal cortex tumors

INTRODUCTION

Laparoscopic adrenalectomy (LA) is the procedure of choice for small benign adrenal tumors. In the absence of local invasion or metastases, the preoperative diagnosis of an adrenocortical carcinoma (ACC) is difficult, often leaving size as the principal predictor of malignancy. Large tumors are resectable laparoscopically, but the long-term outcome and therefore appropriateness of LA for cortical tumors > 6 cm is not known.

METHODS

We reviewed the LA experience in our institution since its introduction in June 1994. Patients who underwent LA for solid cortical tumors > or = 60 mm in diameter without preoperative or intraoperative evidence of malignancy were reviewed. Follow-up data, including clinical examination, biochemical analysis, and repeat scans, were reviewed for evidence of local or systemic recurrent disease.

RESULTS

Between 1994 and 2004 a total of 462 adrenalectomies were performed, 391 of which were done laparoscopically. Among them, 19 were solid cortical tumors > or = 60 mm in diameter with no overt malignant preoperative or intraoperative characteristics: 9 nonsecreting tumors, 8 Cushing's syndrome tumors (including 2 virilizing variants), 1 virilizing tumor, and 1 aldosteronoma. The mean age of the patients was 49.9 years (range 22-77 years), and the mean tumor size was 69.0 mm (range 60-80 mm). Histology confirmed a cortical adenoma in eight patients, malignant tumors in three, and indeterminate tumors in eight. The mean follow-up was 34 months (range 4-108 months). Two patients died of systemic recurrent disease (liver metastases) at 10 and 19 months, respectively, following surgery; two other patients died 12 and 21 months, respectively following surgery owing to unrelated cardiovascular and cerebrovascular pathology. One patient underwent surgery for local recurrence 54 months after primary surgery; the remaining 14 patients are well with no clinical or radiologic evidence of recurrent disease.

CONCLUSIONS

Laparoscopic adrenalectomy for large solid cortical tumors without pre- or intraoperative evidence of malignancy is not contraindicated, and it is unlikely to have a deleterious effect on long-term outcome. Each case should be considered individually. We provide an algorithm for the approach to adrenocortical tumors > or = 6 cm.

Adrenocortical carcinoma

ACC is a rare clinical entity that carries a poor prognosis; early diagnosis and complete surgical resection are associated with the improvement in patient survival. Even with appropriated diagnosis and treatment, most patients will develop recurrence and succumb to ACC because of the underlying tumor biology, the difficulty of achieving a complete resection, and the lack of effective systemic therapies. Despite its many drawbacks, mitotane continues to be a mainstay in the treatment of high-risk patients with ACC, especially those with recurrent or metastatic disease. Recent findings suggest that mitotane, combined with conventional chemotherapeutic agents, may improve survival for such patients.

Evaluation of an adrenal mass in a patient with progressive prostate cancer reveals pheochromocytoma

Adrenal masses in cancer patients pose diagnostic problems. We report the case of a 59 years old male with a history of prostate cancer who presented to us with serially rising prostate specific antigen. On imaging studies he had bone lesions and in addition had a 1.7 cm left adrenal mass. Since metastasis to the adrenal gland has rarely been reported in prostate cancer, and since the radiological criteria in our case favored malignancy, we proceeded with hormonal evaluation and fine needle aspiration biopsy of the adrenal mass which proved it to be pheochromocytoma. This was followed by an uneventful adrenalectomy.

Adrenocortical carcinoma

PURPOSE OF REVIEW

Adrenocortical carcinoma is a rare malignancy, accounting for 0.02% of all annual cancers reported. Given the generally advanced stage at diagnosis, the overall 5-year survival remains poor, varying between 20 and 45%. While older studies purported an improved outcome for functional tumors in adult patients, this has not been borne out in more recent studies. In the pediatric population, though, virilizing tumors carry a better survival than non-functional or cortisol-secreting tumors.

RECENT FINDINGS

Recent studies focusing on the tumorigenesis of adrenocortical carcinoma have focused on onco-developmental genes present in the fetal adrenal cortex, as well as local adrenal paracrine and autocrine effects of cellular peptides.

SUMMARY

Pre-operative diagnostic advances in positron emission scanning are emerging as promising modalities for confirmation of malignancy of indeterminate adrenal masses. No significant advances in the treatment of adrenocortical carcinoma have been developed. Surgery remains the mainstay for primary and recurrent disease, including select patients with isolated liver metastases. Mitotane has remained the preferred adjuvant treatment agent, showing modest effect in patients with unresectable, residual or metastatic disease. Multi-institutional registries and trials need to be established, with multidisciplinary efforts focused on the development of new therapeutic strategies.

Laparoscopic resection of adrenal cortical carcinoma: a cautionary note

BACKGROUND

While laparoscopic removal of small, benign, functioning adrenal tumors is accepted, laparoscopic resection of adrenal tumors that may be adrenal cortical carcinoma (ACC) remains controversial.

METHODS

The records of all patients with ACC evaluated at a single institution from 1991 through 2004 were reviewed retrospectively.

RESULTS

Among 170 patients with ACC, 153 patients underwent open anterior adrenalectomy, 6 underwent laparoscopic adrenalectomy, 1 was treated via an open flank approach, and 10 had no operation. At a median follow-up of 28 months, 115 (86%) of 133 patients who had undergone open anterior resection of primary ACC had had a recurrence. Local recurrence and peritoneal carcinomatosis were components of initial failure in 46 (35%) and 11 patients (8%), respectively. In contrast, all 6 patients who underwent laparoscopic resection of ACC had recurrences, and peritoneal carcinomatosis was a component of initial failure in 5 (83%) of them (open vs laparoscopic resection, Fisher exact test P = .0001).

CONCLUSIONS

Laparoscopic resection of ACC is associated with a high risk of peritoneal carcinomatosis. Open adrenalectomy remains the standard of care for patients presenting with an adrenal cortical tumor for which ACC is in the differential diagnosis.

Malignant adrenal tumors

Adrenal tumors, apart from neuroblastoma, are relatively rare in infancy and childhood. Most adrenal lesions are benign, and both benign and malignant tumors may be hormonally active thus, making accurate preoperative diagnosis difficult. The two main malignant tumors are adrenocortical carcinoma and pheochromocytoma. In both tumors, it may be difficult to determine benign from malignant and the biologic behavior and degree of invasion may portend a more malignant course. Surgical excision is the primary therapy for both tumors, including excision of metastatic and recurrent tumor. An open procedure should be considered for invasive adrenocortical carcinoma and in pheochromocytomas in which preoperative imaging demonstrates metastatic nodal disease. A laparoscopic approach is preferred for lesions in which preoperative imaging demonstrates a localized lesion. Chemotherapy, although without proven efficacy, is utilized in some children with metastatic or unresectable disease.

Le système de weiss : un outil toujours d’actualité pour le diagnostic de malignité des tumeurs de la corticosurrenale

Adrenocortical carcinomas are rare tumors. In the absence of the gold standard that constitutes metastases, local invasion or recurrence, the diagnosis of malignancy may represent a great challenge for both clinicians and pathologists. Several multiparametric systems have been developed to assess this malignancy. Among them, the Weiss system, established in 1984 and based on nine microscopic criteria, appears to be the most employed because of its simplicity and reliability. The presence of three and more criteria is in favor of malignancy. However, the application of such system is not devoid of difficulties and subjectivity. A more precise definition of the different microscopic criteria and the proposition of a modified Weiss system based on the most reliable criteria could help. Besides, the Weiss system is of limited value for the diagnosis of malignancy in oxyphil tumors and children tumors of the adrenal cortex.

Laparoscopic adrenalectomy for primary and secondary malignant adrenal tumors

Laparoscopic adrenalectomy is unanimously recognized as the gold standard for the treatment of adrenal tumors, but it is not indicated for tumors of any size when invasion of the surrounding tissues is clearly detected by preoperative imaging. Although laparoscopic adrenalectomy for metastatic adrenal malignancy is a feasible procedure, in the case of primary adrenal malignancy, it should be done very carefully. When laparoscopic surgery is performed for adrenal tumors >6 cm or for tumors that are considered potentially malignant after preoperative imaging or endocrine studies, the operation should be performed only by a highly skilled laparoscopic surgeon. It is also important to inform the patient and family that the tumors may be malignant and that conversion to open surgery could be necessary. The surgeon must create a sufficiently wide working space, remove the tumor and surrounding fat en bloc, and never grasp the tumor or adrenal tissue. The ultrasonically activated scalpel or ultrasonic endoaspirator should be carefully handled so that it does not touch the tumor surface because this will create a risk of tumor-cell dissemination. It also is essential not to persist unreasonably with laparoscopic procedures but to switch immediately to open surgery when laparoscopic surgery becomes difficult.

Synchronous Mediastinal Ganglioneuroma and Retroperitoneal Pheochromocytoma

We herein report the case of a 52-year-old woman who has mediastinal ganglioneuroma and retroperitoneal pheochromocytoma with different histologic entity. The patient first visited our hospital for surgical treatment of superior-posterior mediastinal tumor, which was successfully removed by thoracoscopic approach to reveal a benign ganglioneuroma. A retroperitoneal tumor was incidentally found postoperatively that was removed using a laparoscopic procedure. The retroperitoneal tumor was a nonfunctioning pheochromocytoma, which was different from the mediastinal neurogenic tumor. This association, although rare, should be recognized for management of neurogenic tumors in the thorax.