Adrenal Masses In Children Research Articles

Adrenal masses in children: Imaging, surgical treatment and outcome

Background/objectiveThis study aims to evaluate the current surgical approach to adrenal masses in the pediatric age group. MethodsWe retrospectively analyzed cases that underwent surgery for adrenal masses between 2007 and 2017. Patients were assessed regarding age, sex, primary diagnosis, image defined risk factors (IDRF), surgical treatment method, complications, duration of hospital stay, and follow-up. ResultsWe examined 50 patients who underwent surgery for adrenal mass (mean age: 4.8 years; range: 5 days–14 years). For IDRF assessment, Ultrasonography was used in 42, Computed Tomography in 36, and Magnetic Resonance Imaging in 36 patients. Lesions were present on the right in 25, left in 21, and bilateral in 4 patients. Histopathological findings were neuroblastoma (n = 29), ganglioneuroma (n = 6), adrenal cortex tumor (n = 5), ganglioneuroblastoma (n = 4), pheochromocytoma (n = 3), cyst (n = 1), and adrenal hematoma (n = 2). Laparotomy was performed on 37 patients, and laparoscopy on 13 patients. None of the cases had any operative complications. ConclusionThe crucial factors determining the surgical approach to adrenal masses in pediatric cases are the histopathology of the mass, volume, and IDRF. Minimally invasive procedures could be reliably performed in appropriate cases.

Key Imaging Appearances of Commonly Encountered Pediatric Adrenal Masses

Adrenal masses in children may occur as a result of neoplasm, hemorrhage, infection, or cysts. Ultrasound is the initial imaging modality of choice in suspected adrenal pathology in children. Computed tomography, magnetic resonance imaging, and functional imaging are usually required for confirmation and further characterization of adrenal lesions. This review article highlights the imaging features of common adrenal masses that may involve the adrenal gland in pediatric population.

Laparoscopic approach for adrenal masses in children

Laparoscopic approach for adrenal masses in children

Transperitoneal Laparoscopic Adrenalectomy in Children

Introduction: The use of a minimally invasive approach for adrenalectomy is poorly defined in pediatric patients, although laparoscopic adrenalectomy is considered a standard procedure in adults.1–4 The aim of our video is to describe the safety and feasibility of transperitoneal lateral laparoscopic adrenalectomy in children based on surgical skills and results. Surgical Procedure: The patient was placed in a reverse Trendelenburg semilateral position over a flank lift. A 10 mm Hg pneumoperitoneum was created using a 10- to 12-mm Hasson's trocar and three 5-mm trocars were inserted, as shown in the video. Left Adrenalectomy: A plane along the anterior surface of the kidney, lateral and dorsal to the spleen and tail of pancreas, was established and the splenic ligaments were divided. The dissection proceeded along the anterior surface of the kidney and adrenal gland until the inferior and medial border. The main adrenal vein and artery were isolated and sectioned. The dissection proceeded in a superolateral direction until complete mobilization of the gland. Right Adrenalectomy: The liver was retracted and the right lobe was mobilized, thus revealing the anterior surface of the adrenal gland. The lateral border of the inferior vena cava was isolated to identify the adrenal vein transacted. The dissection proceeded in a mediolateral and superoinferior direction, until complete mobilization of the gland. Materials and Methods: This is a retrospective study of four pediatric laparoscopic adrenalectomies (two right and two left) performed at our center. Preoperative workup included endocrinologic and radiologic investigation to determine the secretory activity, size, and local extent of the lesion. Results: The mean age was 87 months. Indications for surgery were two neuroblastomas, one aldosterone-secreting adrenocortical tumor, and one adrenocortical nodular hyperplasia. The mean size of the lesions was 3.23 cm at the pathologic examination. No intraoperative complications or conversions occurred. The average operating time was 85 minutes for right and 125 minutes for left adrenalectomies. The mean hospital stay was 3.75 days. At 15 months, the follow-up was negative. Conclusions: Transperitoneal laparoscopic adrenalectomy is a safe, feasible, and reproducible approach for the treatment of benign and malignant adrenal masses in children. Furthermore, this approach offers many advantages, including shortening of operating times and postoperative hospital stays, as well as reduction of blood loss and complications; also, a large working space with a clear view of the structure that permitted to perform a controlled resection.5,6 The authors have nothing to disclose. Runtime of video: 8 mins

Surgical technique: Retroperitoneoscopic approach for adrenal masses in children

Laparoscopic adrenalectomy is considered to be the standard of care for the surgical excision of adrenal masses. The transperitoneal laparoscopic and retroperitoneoscopic approaches are described. Both are safe and as effective as open adrenalectomy, with the added benefit of the minimally invasive approach. It can be utilized for patients requiring surgery for a phaeochromocytoma, adrenal adenoma, adrenal adenocarcinoma, Cushing's syndrome, neuroblastoma, and an incidentaloma. Relative contraindications include previous surgery of the liver or kidney, large tumours (>8–10 cm in diameter) or coagulation disorders. Although the transperitoneal route is used more widely, the retroperitoneal approach provides direct access to the adrenal gland and easy visualization of the adrenal vein. It avoids also colonic mobilization, minimizes the risk of injury to hollow viscera, and the potential risk of adhesion formation. However, the reversed orientation of the kidney and hilum, combined with a significantly smaller working space, may make this approach difficult to master.

Laparoscopic adrenalectomy in children

PurposeReporting on the laparoscopic technique for adrenal disease in children and adolescents has been limited. We review here our experience with laparoscopic adrenal surgery in children. Patients and methods19 laparoscopic unilateral adrenalectomies were performed in 10 girls and 7 boys (mean age 3.9 years) during 1998–2011. The clinical diagnosis before surgery was virilizing tumor (n = 8), pheochromocytoma (n = 3), nonfunctioning solid adrenal tumor (n = 3), mixed adrenocortical tumor (n = 2), cystic adrenal mass (n = 1). Unilateral adrenal lesions were 20–65 mm at the longest axis on computerized tomography (12 right side, 7 left side). ResultsThe final clinicopathological diagnosis was cortical adenoma (n = 9), pheochromocytoma (n = 3, bilateral in two), neuroblastoma (n = 1), ganglioneuroblastoma (n = 1), ganglioneuroma (n = 1), adrenocortical carcinoma (n = 1), benign adrenal tissue (n = 1). Average operative time was 138.5 min (range 95–270). Blood transfusion was required in one case (5%). No conversion to open surgery was required and no deaths or postoperative complications occurred. Average hospital stay was 3.5 days (range 2–15). Average postoperative follow-up was 81 months (range 2–144). Two contralateral metachronic pheochromocytomas associated with von Hippel-Lindau syndrome occurred, treated with partial laparoscopic adrenalectomy (one without postoperative need of cortisone replacement therapy). ConclusionsLaparoscopic adrenalectomy is a feasible procedure that produces good results. It can be used safely to treat suspected benign and malignant adrenal masses in children with minimal morbidity and short hospital stay.

Laparoscopic adrenalectomy for adrenal masses in children

Objective The laparoscopic approach to the adrenal gland was first reported in 1992. Since then numerous studies have been published, comprising of adults. Experience with the laparoscopic technique for adrenal disease in children and adolescents has been limited. We have reviewed our experience with laparoscopic adrenal surgery in children. Patients and methods All children with pathologic adrenal masses undergoing laparoscopic adrenal surgery were included. The primary study outcome measures included operative time, conversion to open surgery, complications, duration of hospital stay and outcome of surgery. Results Eighteen children underwent laparoscopic adrenalectomy during the period January 2003–July 2009. The mean operating time was 95 min, mean blood loss was 30 ml and the average postoperative hospital stay was 50 h. There were no conversions to open surgery and no major intra- or postoperative complications noted. Conclusions Laparoscopic adrenalectomy is a safe and feasible procedure with good results. It can be used to safely treat suspected benign and malignant adrenal masses in children with minimal morbidity and a shorter hospital stay.

IPEG Guidelines for the Surgical Treatment of Adrenal Masses in Children

Laparoscopic adrenalectomy and adrenal biopsy are technically feasible in children. There are no absolute contraindications to the laparoscopic approach, but for neuroblastomas and other adrenal neoplasms, care must be taken to maintain the principles of cancer surgery. As opposed to adults, there are fewer benign indications for adrenalectomy, but in selected cases, laparoscopic resection of the adrenal is feasible. Both laparoscopic and retroperitoneoscopic approaches are recommended, with the choice being dictated by the experience of the surgeon. Recommendations throughout this guideline are based on class 3 evidence, with a single article demonstrating class 2 evidence, based on a retrospective comparison.

Adrenal Masses in Children

The development of laparoscopic surgery has extended its uses to include adrenalectomy in children and in adults. Because conventional adrenalectomy requires a large incision, minimally invasive surgery offers a less aggressive solution in some selected cases. Twenty-nine adrenal masses in 26 children were treated using adrenalectomy between 1994 and 2004 (12 were treated laparoscopically, the remaining 17 with open surgery). Minimally invasive procedures were limited to the removal of small localized adrenal tumors and to biopsies. Although this approach must be limited to operations on lesions presumed to be benign, preoperative criteria for nonmalignancy are often difficult to define. Indications can be expanded to include to stage I neuroblastoma. There seems to be no age and weight limit. The technique applied varies in accordance with anatomy and the surgeon's experience: minimally invasive adrenalectomy, in our experience, was preferentially performed through a lateral retroperitoneal approach. Laparoscopic adrenalectomy can be used if the selection of cases is rigorous and the operations are performed by well-trained laparoscopic surgeons.

Is Surgery Necessary for Incidentally Discovered Adrenal Masses in Children?

No AccessJournal of UrologyUrological Survey: Adrenal and Renal Physiology, and Medical Renal Disease1 Oct 2005Is Surgery Necessary for Incidentally Discovered Adrenal Masses in Children? W. Scott McDougalM.D. W. Scott McDougalW. Scott McDougal More articles by this author View All Author Informationhttps://doi.org/10.1097/S0022-5347(01)68669-5AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Is Surgery Necessary for Incidentally Discovered Adrenal Masses in Children?." The Journal of Urology, 174(4 Part 1), p. 1446 © 2005 by American Urological Association, Inc.FiguresReferencesRelatedDetails Volume 174Issue 4 Part 1October 2005Page: 1446 Advertisement Copyright & Permissions© 2005 by American Urological Association, Inc.MetricsAuthor Information W. Scott McDougal More articles by this author Expand All Advertisement PDF DownloadLoading ...

The Safety and Efficacy of Laparoscopic Adrenalectomy in Children—Invited Critique

Hypothesis: Laparoscopic adrenalectomy (LA) has become standard therapy for benign adrenal masses in adults. The utility of LA in children with adrenal masses is less well defined because of the infrequency and pathologic variability of pediatric adrenal masses, and body size and instrumentation considerations that exist in small children. Evaluation of a case series of children undergoing lateral, transperitoneal LA will reflect the safety and efficacy of this procedure in pediatric patients and identify preferred patient selection criteria. Design: A combined case series including patients treated between March 1999 and November 2004. Setting: Urban tertiary referral pediatric teaching hospitals. Patients and Interventions: All children with pathologic adrenal masses undergoing LA were included. Main Outcome Measures: The primary study outcome measures included operative duration, conversions to open adrenalectomy, complications, length of hospital stay, and freedom from recurrence of the original pathologic adrenal mass. Results: A total of 21 LAs (including a staged, bilateral LA) were performed in 20 patients (13 girls, 7 boys) with a mean age of 6.4 years (range, 14 months to 18 years). Nine patients (43%) had neuroblastic tumors. Operative duration averaged mean±SD 101±48 minutes, and there was a single conversion to open adrenalectomy in a patient with a left adrenal carcinoma and tumor thrombus extending into the renal vein. There were no peri-operative complications, and no patients required blood transfusions. The postoperative hospital stay averaged 1.5 days (range, 1-4.5 days). At a mean±SD follow-up of 31±17 months, all patients remained clinically (radiologically and/or biochemically) free of their original adrenal disease. Conclusion: Laparoscopic adrenalectomy can be used to safely treat suspected benign and selected malignant adrenal masses in children.

The Safety and Efficacy of Laparoscopic Adrenalectomy in Children

Laparoscopic adrenalectomy (LA) has become standard therapy for benign adrenal masses in adults. The utility of LA in children with adrenal masses is less well defined because of the infrequency and pathologic variability of pediatric adrenal masses, and body size and instrumentation considerations that exist in small children. Evaluation of a case series of children undergoing lateral, transperitoneal LA will reflect the safety and efficacy of this procedure in pediatric patients and identify preferred patient selection criteria. A combined case series including patients treated between March 1999 and November 2004. Urban tertiary referral pediatric teaching hospitals. All children with pathologic adrenal masses undergoing LA were included. The primary study outcome measures included operative duration, conversions to open adrenalectomy, complications, length of hospital stay, and freedom from recurrence of the original pathologic adrenal mass. A total of 21 LAs (including a staged, bilateral LA) were performed in 20 patients (13 girls, 7 boys) with a mean age of 6.4 years (range, 14 months to 18 years). Nine patients (43%) had neuroblastic tumors. Operative duration averaged mean +/- SD 101 +/- 48 minutes, and there was a single conversion to open adrenalectomy in a patient with a left adrenal carcinoma and tumor thrombus extending into the renal vein. There were no perioperative complications, and no patients required blood transfusions. The postoperative hospital stay averaged 1.5 days (range, 1-4.5 days). At a mean +/- SD follow-up of 31 +/- 17 months, all patients remained clinically (radiologically and/or biochemically) free of their original adrenal disease. Laparoscopic adrenalectomy can be used to safely treat suspected benign and selected malignant adrenal masses in children.

Is surgery necessary for incidentally discovered adrenal masses in children?

Background There are no guidelines that exist to direct the management of incidental adrenal masses (IAM) in children. The aim of this study was to determine if there is a subset of IAMs that could be safely observed. Methods A retrospective analysis was conducted of all adrenal masses that were either resected or biopsied between 1990 and 2002 (n = 91) at the Hospital for Sick Children, Toronto. IAM was defined as a solitary adrenal mass discovered by either physical examination (n = 6; 23.1%) or diagnostic imaging for other indications (n = 20; 76.9%), without metastases or biochemical activity. Results Twenty-six (28.6%) IAMs were detected (mean age, 4.6 years [range, antenatal to 17 years]; 11 boys, 15 girls). Pathologic diagnoses included neuroblastoma (n = 7), ganglioneuroma (n = 6), adrenocortical adenoma (n = 4), adrenal cyst/pseudocyst (n = 3), adrenal hemorrhage (n = 3), ganglioneuroblastoma (n = 1), nodular cortical hyperplasia (n = 1), and teratoma (n = 1). Eight masses were malignant (30.8%). Two of the 5 masses discovered on antenatal ultrasound scan were neuroblastoma. In comparing the benign with malignant lesions, there was no significant difference in mean size (4.8 cm v 4.3 cm; P = .57), radiologic characteristics, or mode of presentation. Benign lesions occurred more frequently in older children (mean age, 6.5 years v 1.3 years; P = .03). Conclusions Clear guidelines cannot be established to predict benign IAM in children. Given the high proportion of malignant lesions, we recommend that all pediatric IAMs should be resected.

Integrated Imaging for the Evaluation of the Urologic Diseases of Childhood

The rational selection of imaging modalities for the diagnosis of renal and adrenal masses in children is discussed with a view toward obtaining an accurate assessment of pathologic changes with the least amount of stress and expense to the patient. The integration of the results of these tests in specific clinical settings is also described.