-
Best Practice & Research. Clinical... Mar 2020Overt Cushing's syndrome is a severe condition responsible for multiple comorbidities and increased mortality. Effective treatment is essential to reduce mortality,... (Review)
Review
Overt Cushing's syndrome is a severe condition responsible for multiple comorbidities and increased mortality. Effective treatment is essential to reduce mortality, improve comorbidities and long-term quality of life. Surgical resection of the causal lesion(s) is generally the first-line and most effective treatment to normalize cortisol secretion. Adjunctive symptomatic treatments of co-morbidities are often necessary both during the active phase of the disease and for persisting co-morbidities after cessation of hypercortisolism. Second-line treatments include various pharmacological treatments, bilateral adrenalectomy, and radiotherapy of corticotroph tumors. The choice of these treatments is complex, must be performed in a multidisciplinary expert team to be individualized for each patient, and use a shared decision-making approach.
Topics: Adrenalectomy; Cushing Syndrome; Diagnostic Techniques, Endocrine; Humans; Quality of Life; Therapies, Investigational; Treatment Outcome
PubMed: 32035797
DOI: 10.1016/j.beem.2020.101381 -
The Veterinary Clinics of North... Mar 2022Surgical removal is the standard of care for adrenal tumors greater than 2.0 cm diameter. For tumors smaller than 2.0 cm, imaging techniques evaluating patterns of... (Review)
Review
Surgical removal is the standard of care for adrenal tumors greater than 2.0 cm diameter. For tumors smaller than 2.0 cm, imaging techniques evaluating patterns of contrast washout may offer a promising avenue for early identification of adrenal malignancy. Pretreatment of pheochromocytoma with phenoxybenzamine is associated with reduced surgical mortality risk. Surgical technique can be laparoscopic or open, depending on tumor anatomy and the experience of the surgeon. Vascular invasion is a contraindication for a laparoscopic technique. This review provides a summary of minimally invasive and open adrenalectomy techniques, including a discussion of management of vascular invasion and partial cavectomy.
Topics: Adrenal Gland Neoplasms; Adrenalectomy; Animals; Laparoscopy; Pheochromocytoma
PubMed: 35210060
DOI: 10.1016/j.cvsm.2021.12.005 -
JAMA Surgery Oct 2022Adrenalectomy is the definitive treatment for multiple adrenal abnormalities. Advances in technology and genomics and an improved understanding of adrenal...
IMPORTANCE
Adrenalectomy is the definitive treatment for multiple adrenal abnormalities. Advances in technology and genomics and an improved understanding of adrenal pathophysiology have altered operative techniques and indications.
OBJECTIVE
To develop evidence-based recommendations to enhance the appropriate, safe, and effective approaches to adrenalectomy.
EVIDENCE REVIEW
A multidisciplinary panel identified and investigated 7 categories of relevant clinical concern to practicing surgeons. Questions were structured in the framework Population, Intervention/Exposure, Comparison, and Outcome, and a guided review of medical literature from PubMed and/or Embase from 1980 to 2021 was performed. Recommendations were developed using Grading of Recommendations, Assessment, Development and Evaluation methodology and were discussed until consensus, and patient advocacy representation was included.
FINDINGS
Patients with an adrenal incidentaloma 1 cm or larger should undergo biochemical testing and further imaging characterization. Adrenal protocol computed tomography (CT) should be used to stratify malignancy risk and concern for pheochromocytoma. Routine scheduled follow-up of a nonfunctional adrenal nodule with benign imaging characteristics and unenhanced CT with Hounsfield units less than 10 is not suggested. When unilateral disease is present, laparoscopic adrenalectomy is recommended for patients with primary aldosteronism or autonomous cortisol secretion. Patients with clinical and radiographic findings consistent with adrenocortical carcinoma should be treated at high-volume multidisciplinary centers to optimize outcomes, including, when possible, a complete R0 resection without tumor disruption, which may require en bloc radical resection. Selective or nonselective α blockade can be used to safely prepare patients for surgical resection of paraganglioma/pheochromocytoma. Empirical perioperative glucocorticoid replacement therapy is indicated for patients with overt Cushing syndrome, but for patients with mild autonomous cortisol secretion, postoperative day 1 morning cortisol or cosyntropin stimulation testing can be used to determine the need for glucocorticoid replacement therapy. When patient and tumor variables are appropriate, we recommend minimally invasive adrenalectomy over open adrenalectomy because of improved perioperative morbidity. Minimally invasive adrenalectomy can be achieved either via a retroperitoneal or transperitoneal approach depending on surgeon expertise, as well as tumor and patient characteristics.
CONCLUSIONS AND RELEVANCE
Twenty-six clinically relevant and evidence-based recommendations are provided to assist surgeons with perioperative adrenal care.
Topics: Adrenal Gland Neoplasms; Adrenalectomy; Cosyntropin; Glucocorticoids; Humans; Hydrocortisone; Pheochromocytoma; Surgeons
PubMed: 35976622
DOI: 10.1001/jamasurg.2022.3544 -
The Surgical Clinics of North America Aug 2019Primary hyperaldosteronism is an important and increasingly prevalent cause of hypertension that is characterized by unregulated aldosterone excess. More than 90% of... (Review)
Review
Primary hyperaldosteronism is an important and increasingly prevalent cause of hypertension that is characterized by unregulated aldosterone excess. More than 90% of primary hyperaldosteronism cases are attributable to either idiopathic adrenal hyperplasia or aldosterone-producing adenomas. The approach to the diagnosis of primary hyperaldosteronism should be step-wise, starting with screening of at-risk populations, confirmatory testing for positively screened patients, and subtype classification in order to direct surgical or medical management. Based on current guidelines, subtype classification of primary hyperaldosteronism should be determined with both imaging and adrenal vein sampling (AVS), reserving deferment of AVS for a selective subset of patients.
Topics: Adrenalectomy; Diagnosis, Differential; Disease Management; Humans; Hyperaldosteronism; Tomography, X-Ray Computed
PubMed: 31255203
DOI: 10.1016/j.suc.2019.04.010 -
The Journal of Clinical Endocrinology... Jan 2021Develop a consensus for the nomenclature and definition of adrenal histopathologic features in unilateral primary aldosteronism (PA).
OBJECTIVE
Develop a consensus for the nomenclature and definition of adrenal histopathologic features in unilateral primary aldosteronism (PA).
CONTEXT
Unilateral PA is the most common surgically treated form of hypertension. Morphologic examination combined with CYP11B2 (aldosterone synthase) immunostaining reveals diverse histopathologic features of lesions in the resected adrenals.
PATIENTS AND METHODS
Surgically removed adrenals (n = 37) from 90 patients operated from 2015 to 2018 in Munich, Germany, were selected to represent the broad histologic spectrum of unilateral PA. Five pathologists (Group 1 from Germany, Italy, and Japan) evaluated the histopathology of hematoxylin-eosin (HE) and CYP11B2 immunostained sections, and a consensus was established to define the identifiable features. The consensus was subsequently used by 6 additional pathologists (Group 2 from Australia, Brazil, Canada, Japan, United Kingdom, United States) for the assessment of all adrenals with disagreement for histopathologic diagnoses among group 1 pathologists.
RESULTS
Consensus was achieved to define histopathologic features associated with PA. Use of CYP11B2 immunostaining resulted in a change of the original HE morphology-driven diagnosis in 5 (14%) of 37 cases. Using the consensus criteria, group 2 pathologists agreed for the evaluation of 11 of the 12 cases of disagreement among group 1 pathologists.
CONCLUSION
The HISTALDO (histopathology of primary aldosteronism) consensus is useful to standardize nomenclature and achieve consistency among pathologists for the histopathologic diagnosis of unilateral PA. CYP11B2 immunohistochemistry should be incorporated into the routine clinical diagnostic workup to localize the likely source of aldosterone production.
Topics: Adrenal Glands; Adrenalectomy; Adult; Cohort Studies; Consensus; Cytochrome P-450 CYP11B2; Cytodiagnosis; Diagnostic Techniques, Endocrine; Female; Germany; Histological Techniques; Humans; Hyperaldosteronism; Hypertension; Immunohistochemistry; Internationality; Male; Middle Aged; Practice Guidelines as Topic; Societies, Medical
PubMed: 32717746
DOI: 10.1210/clinem/dgaa484 -
Endocrinology and Metabolism (Seoul,... Dec 2020Since the introduction of minimally invasive surgery, laparoscopic adrenalectomy has become the main treatment option for adrenal masses. Various studies have reported... (Review)
Review
Since the introduction of minimally invasive surgery, laparoscopic adrenalectomy has become the main treatment option for adrenal masses. Various studies have reported that laparoscopic adrenalectomy showed fewer postoperative complications and faster recovery than conventional open adrenalectomy. Laparoscopic adrenalectomy can be performed through either the transperitoneal approach or the retroperitoneoscopic approach, which are widely used in most adrenal surgical procedures. Furthermore, with the development of minimally invasive surgery, organ-sparing adrenalectomy has recently emerged as a way to conserve functional adrenal gland tissue. According to recent data, organ-sparing adrenalectomy shows promising surgical, functional, and oncological outcomes including less intraoperative blood loss, maintenance of adrenal function, and low recurrence. Partial adrenalectomy was initially proposed for bilateral adrenal tumors in patients with hereditary disease to avoid chronic adrenal insufficiency. However, it has also gained popularity for the treatment of unilateral adrenal disease involving a small adrenal tumor because even patients with a unilateral adrenal gland may develop adrenal insufficiency in stressful situations. Therefore, partial adrenalectomy has become increasingly common to avoid lifelong steroid replacement and recurrence in most cases, especially in bilateral adrenal disease. This review article evaluates the current evidence on minimally invasive adrenalectomy and organ-preserving partial adrenalectomy.
Topics: Adrenal Gland Neoplasms; Adrenalectomy; Blood Loss, Surgical; Humans; Intraoperative Complications; Laparoscopy; Length of Stay; Minimally Invasive Surgical Procedures; Operative Time; Pain, Postoperative; Postoperative Complications; Randomized Controlled Trials as Topic
PubMed: 33397038
DOI: 10.3803/EnM.2020.404 -
Endocrinology and Metabolism Clinics of... Sep 2019Pheochromocytoma during pregnancy, although rare, is a perilous condition. The wellbeing of mother and fetus are at stake if not diagnosed and treated antenatally and... (Review)
Review
Pheochromocytoma during pregnancy, although rare, is a perilous condition. The wellbeing of mother and fetus are at stake if not diagnosed and treated antenatally and timely. The diagnosis is frequently overlooked because of the aspecific nature of signs and symptoms and confusion with pregnancy-related hypertension. Measurements of plasma or urinary free metanephrines have the highest diagnostic accuracy. MRI is preferred over ultrasonography. The optimal time for surgical removal is before 24 weeks of gestation or at/after delivery. Laparoscopic adrenalectomy should be preceded by medical pretreatment. Cesarean delivery is preferred in these patients; vaginal delivery might be considered in selected pretreated patients.
Topics: Adrenal Gland Neoplasms; Adrenalectomy; Female; Humans; Magnetic Resonance Imaging; Metanephrine; Pheochromocytoma; Pregnancy; Pregnancy Complications, Neoplastic; Ultrasonography
PubMed: 31345526
DOI: 10.1016/j.ecl.2019.05.006 -
The Surgical Clinics of North America Aug 2019Adrenocortical cancer is a rare disease. Prognosis remains poor but is improving. In this article, initial presentation, biochemical and imaging evaluation, surgical... (Review)
Review
Adrenocortical cancer is a rare disease. Prognosis remains poor but is improving. In this article, initial presentation, biochemical and imaging evaluation, surgical approach to resection, and postoperative care are reviewed. Prognosis, patterns of recurrence, treatment of metastatic disease using medical therapy and other surgical and nonsurgical therapies are discussed.
Topics: Adrenal Cortex Neoplasms; Adrenalectomy; Adrenocortical Carcinoma; Antineoplastic Agents; Chemotherapy, Adjuvant; Humans; Treatment Outcome
PubMed: 31255205
DOI: 10.1016/j.suc.2019.04.012 -
Experimental and Clinical Endocrinology... Aug 2023The radiofrequency ablation (RFA) technique has been extensively used in the treatment of primary malignancies and metastases and has been recently deployed for the... (Review)
Review
The radiofrequency ablation (RFA) technique has been extensively used in the treatment of primary malignancies and metastases and has been recently deployed for the treatment of unilateral primary aldosteronism (PA) as an alternative to whole unilateral adrenalectomy.Current evidence comparing RFA with unilateral adrenalectomy in the treatment of PA so far has been variable, with studies being retrospective and small-scale, but it remains a very attractive option as a potentially less invasive treatment option compared to adrenalectomy.This review article describes the procedure, and provides evidence and the possible future direction of RFA in the treatment of unilateral PA.
Topics: Humans; Hyperaldosteronism; Retrospective Studies; Adrenalectomy; Radiofrequency Ablation; Treatment Outcome; Catheter Ablation
PubMed: 37442160
DOI: 10.1055/a-2128-5811 -
Current Opinion in Endocrinology,... Jun 2023Review the literature on the surgical management of adrenal diseases, highlighting the various surgical approaches and their respective pros and cons. (Review)
Review
PURPOSE OF REVIEW
Review the literature on the surgical management of adrenal diseases, highlighting the various surgical approaches and their respective pros and cons.
RECENT FINDINGS
Minimally invasive adrenalectomy is commonly used for small and benign adrenal tumors, whereas open adrenalectomy is preferred for larger tumors and primary adrenal malignancy. Although minimally invasive adrenalectomy results in shorter recovery and fewer complications compared with open, the latter offers better oncologic outcomes in the setting of primary adrenal malignancy. Adrenalectomy is performed transabdominally or retroperitoneoscopically, both yielding equivalent results and recovery. Traditional laparoscopic or robotic equipment can be utilized for either minimally invasive approach. Subtotal adrenalectomy may be appropriate for patients with genetically associated pheochromocytoma to preserve cortical function and reduce the risk of adrenal insufficiency. However, the potential benefits of sparing adrenal function must be weighed against the risk of recurrence.
SUMMARY
Adrenalectomy is becoming increasingly common worldwide. For benign and small adrenal tumors, minimally invasive adrenalectomy is generally considered the standard approach, while open adrenalectomy is preferred for primary adrenal malignancy and larger tumors. Subtotal adrenalectomy may be appropriate for patients with bilateral adrenal pheochromocytoma, as it can reduce the need for lifelong glucocorticoid dependency.
Topics: Humans; Pheochromocytoma; Adrenal Gland Neoplasms; Adrenal Glands; Laparoscopy; Adrenalectomy
PubMed: 37057653
DOI: 10.1097/MED.0000000000000810