Large Adrenal lesions - Management at a tertiary centre in Greece

Konstantinos Nastos, Georgios Exarchos, Panagiotis T. Arkoumanis, Linda Metaxa, Theodosis Theodosopoulos, Athanasios E. Dellis, Georgios Polymeneas

Abstract


Introduction and Objective: “Large adrenal lesions” are considered tumours with a size varying between 5cm to 10 cm, with a general consensus measuring approximately 6 cm. Adrenal lesions are common with adrenalectomy being the third commonest endocrine procedure. However, large adrenal lesions are rare with an incidence ranging from 8.6% to 38.6% of adrenal tumours. There is evidence that the risk of malignancy increases with a tumour size of more than 4cm. With advances in modern imaging and rapidly aging population, the presentation of an incidentally found adrenal mass has become an increasingly common scenario for endocrine surgeons and Urologists. Resection of large adrenal lesions could be challenging, especially when it is performed laparoscopically. Our aim is to present the surgical outcomes of our patients operated for large adrenal lesions measuring more than 6cm in size and to validate the role of laparoscopic surgery in the management of these tumours.
Methods: This is a retrospective study of patients operated for an adrenal lesion, measuring more than 6cm, in Aretaieio university hospital, between July 2008 and April 2018. Patients underwent open or laparascopic procedure. The preoperative diagnosis, operative details, complications, length of hospital stay, morbidity and follow-up were recorded and tabulated.
Results: 45 patients had lesions over 6cm (47 lesions) with mean size 8.38cm. Out of these 45 patients 25 were female patients, and 20 males, with mean age of 58.2 years. 31.9% of the lesions were found to be malignant with an average size of 11.33cm and the rest were benign with an average size of 7.65cm (pvalue=0.01). Most of the cases operated for an adrenal mass were for Pheochromocytoma (27.7%) that had mean size of 7.5cm, followed by Adenocortical carcinomas (23.4%) and Adenocortical adenomas (21.3%) with mean size of 12.5cm and 6.78cm respectively. 28 out of 47 cases (59.6%) had open surgery, while the rest underwent laparoscopic approach; 13 (25.7%) transabdominal and 6 (12.8%) posterior retroperitoneal approach. The majority of the malignant cases (94%) had open surgery. Although no differences were noticed in the complication rates between open and laparoscopic surgery, there was a statistical significant reduction in the duration of the hospital stay, in the patients treated laparoscopically (mean stay 3.7d over 9.5d, pvalue<0.01).
Conclusion: Laparoscopic resection of large adrenal lesions could be challenging but if expertise is available could be effectively performed. Risks and complications are reduced when the surgical approach is tailored for each patient.


Keywords


large adrenal lesions; pheochromocytoma; adrenocortical carcinoma; malignant; benign; laparoscopic surgery

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References


Bovio S, Cataldi A, Reimondo G, Sperone P, Novello S, Berruti A, et al. Prevalence of adrenal incidentaloma in a contemporary computerized tomography series. Journal of endocrinological investigation. 2006;29(4):298-302.

Joris JL, Hamoir EE, Hartstein GM, Meurisse MR, Hubert BM, Charlier CJ, et al. Hemodynamic changes and catecholamine release during laparoscopic adrenalectomy for pheochromocytoma. Anesthesia and analgesia. 1999;88(1):16-21.

NIH state-of-the-science statement on management of the clinically inapparent adrenal mass (“incidentaloma”). NIH consensus and state-of-the-science statements. 2002;19(2):1-25.

Denzinger S, Burger M, Hartmann A, Hofstaedter F, Wieland WF, Ganzer R. Spontaneous rupture of a benign giant adrenal adenoma. APMIS: acta pathologica, microbiologica, et immunologica Scandinavica. 2007;115(4):381-4.

Mantero F, Arnaldi G. Management approaches to adrenal incidentalomas. A view from Ancona, Italy. Endocrinology and metabolism clinics of North America. 2000;29(1):107-25, ix.

Medeiros LJ, Weiss LM. New developments in the pathologic diagnosis of adrenal cortical neoplasms. A review. American journal of clinical pathology. 1992;97(1):73-83.

Angeli A, Osella G, Ali A, Terzolo M. Adrenal incidentaloma: an overview of clinical and epidemiological data from the National Italian Study Group. Hormone research. 1997;47(4-6):279-83.

Terzolo M, Ali A, Osella G, Mazza E. Prevalence of adrenal carcinoma among incidentally discovered adrenal masses. A retrospective study from 1989 to 1994. Gruppo Piemontese Incidentalomi Surrenalici. Archives of surgery (Chicago, Ill : 1960). 1997;132(8):914-9.

Imai T, Kikumori T, Ohiwa M, Mase T, Funahashi H. A case-controlled study of laparoscopic compared with open lateral adrenalectomy. American journal of surgery. 1999;178(1):50-3; discussion 4.

Smith CD, Weber CJ, Amerson JR. Laparoscopic adrenalectomy: new gold standard. World journal of surgery. 1999;23(4):389-96.

Tanaka M, Ono Y, Matsuda T, Terachi T, Suzuki K, Baba S, et al. Guidelines for urological laparoscopic surgery. International journal of urology : official journal of the Japanese Urological Association. 2009;16(2):115-25.

Conzo G, Tricarico A, Belli G, Candela S, Corcione F, Del Genio G, et al. Adrenal incidentalomas in the laparoscopic era and the role of correct surgical indications: observations from 255 consecutive adrenalectomies in an Italian series. Canadian journal of surgery Journal canadien de chirurgie. 2009;52(6):E281-5.

Brunaud L, Nguyen-Thi PL, Mirallie E, Raffaelli M, Vriens M, Theveniaud PE, et al. Predictive factors for postoperative morbidity after laparoscopic adrenalectomy for pheochromocytoma: a multicenter retrospective analysis in 225 patients. Surgical endoscopy. 2016;30(3):1051-9.

Quayle FJ, Spitler JA, Pierce RA, Lairmore TC, Moley JF, Brunt LM. Needle biopsy of incidentally discovered adrenal masses is rarely informative and potentially hazardous. Surgery. 2007;142(4):497-502; discussion -4.

Liao CH, Chueh SC, Lai MK, Hsiao PJ, Chen J. Laparoscopic adrenalectomy for potentially malignant adrenal tumors greater than 5 centimeters. The Journal of clinical endocrinology and metabolism. 2006;91(8):3080-3.

Germain A, Klein M, Brunaud L. Surgical management of adrenal tumors. Journal of visceral surgery. 2011;148(4):e250-61.

Zografos GN, Farfaras A, Vasiliadis G, Pappa T, Aggeli C, Vassilatou E, et al. Laparoscopic resection of large adrenal tumors. JSLS : Journal of the Society of Laparoendoscopic Surgeons. 2010;14(3):364-8.

Parnaby CN, Chong PS, Chisholm L, Farrow J, Connell JM, O’Dwyer PJ. The role of laparoscopic adrenalectomy for adrenal tumours of 6 cm or greater. Surgical endoscopy. 2008;22(3):617-21.

Tessonnier L, Ansquer C, Bournaud C, Sebag F, Mirallie E, Lifante JC, et al. (18)F-FDG uptake at initial staging of the adrenocortical cancers: a diagnostic tool but not of prognostic value. World journal of surgery. 2013;37(1):107-12.

Combemale F, Carnaille B, Tavernier B, Hautier MB, Thevenot A, Scherpereel P, et al. [Exclusive use of calcium channel blockers and cardioselective beta-blockers in the pre- and per-operative management of pheochromocytomas. 70 cases]. Annales de chirurgie. 1998;52(4):341-5.

Siddiqi HK, Yang HY, Laird AM, Fox AC, Doherty GM, Miller BS, et al. Utility of oral nicardipine and magnesium sulfate infusion during preparation and resection of pheochromocytomas. Surgery. 2012;152(6):1027-36.

Ramacciato G, Paolo M, Pietromaria A, Paolo B, Francesco D, Sergio P, et al. Ten years of laparoscopic adrenalectomy: lesson learned from 104 procedures. The American surgeon. 2005;71(4):321-5.




DOI: http://dx.doi.org/10.19264/hj.v30i2.231