Benign Adrenal Masses Research Articles

An Update of Practical CT Adrenal Imaging: What Physicians Need to Know

Computed tomography (CT) is increasingly being utilized for patient care, with a subsequent increase in the detection of incidental adrenal masses. It is important for physicians to be familiar with the various current and investigational CT techniques used to image and characterize adrenal masses, including noncontrast CT, dual-energy CT, post-contrast imaging with percentage washout calculations, and investigational techniques including histogram, perfusion, and biphasic CT analyses. Once an incidental adrenal mass is detected, it is important to utilize current CT adrenal imaging techniques to characterize adrenal masses and differentiate the indolent adrenal masses that may be left alone from malignant and symptomatic masses that need timely medical or surgical management. Current CT imaging techniques can be utilized to differentiate benign adrenal masses from malignant counterparts. In this article, we describe the common CT features of benign adrenal masses, including hyperplasia, adenoma, pheochromocytoma, and myelolipoma. We also describe the common CT features of malignant adrenal masses, including metastases, and adrenal cortical carcinoma.

Metabolic and anatomic characteristics of benign and malignant adrenal masses on positron emission tomography/computed tomography: a review of literature.

PET/CT with (18)F-fluorodeoxyglucose (FDG) or using different radiocompounds has proven accuracy for detection of adrenal metastases in patients undergoing cancer staging. It can assist the diagnostic work-up in oncology patients by identifying distant metastases to the adrenal(s) and defining oligometastatic disease that may benefit from targeted intervention. In patients with incidentally discovered adrenal nodules, so-called adrenal "incidentaloma" FDG PET/CT is emerging as a useful test to distinguish benign from malignant etiology. Current published evidence suggests a role for FDG PET/CT in assessing the malignant potential of an adrenal lesion that has been 'indeterminately' categorized with unenhanced CT, adrenal protocol contrast-enhanced CT, or chemical-shift MRI. FDG PET/CT could be used to stratify patients with higher risk of malignancy for surgical intervention, while recommending surveillance for adrenal masses with low malignant potential. There are caveats for interpretation of the metabolic activity of an adrenal nodule on PET/CT that may lead to false-positive and false-negative interpretation. Adrenal lesions represent a wide spectrum of etiologies, and the typical appearances on PET/CT are still being described, therefore our goal was to summarize the current diagnostic strategies for evaluation of adrenal lesions and present metabolic and anatomic appearances of common and uncommon adrenal lesions. In spite of the emerging role of PET/CT to differentiate benign from malignant adrenal mass, especially in difficult cases, it should be emphasized that PET/CT is not needed for most patients and that many diagnostic problems can be resolved by CT and/or MR imaging.

Role of endoscopic ultrasound fine-needle aspiration evaluating adrenal gland enlargement or mass.

To report the clinical impact of adrenal endoscopic ultrasound fine-needle aspiration (EUS-FNA) in the evaluation of patients with adrenal gland enlargement or mass. In a retrospective single-center case-series, patients undergoing EUS-FNA of either adrenal gland from 1997-2011 in our tertiary care center were included. Medical records were reviewed and results of EUS, cytology, adrenal size change on follow-up imaging ≥ 6 mo after EUS and any repeat EUS or surgery were abstracted. A lesion was considered benign if: (1) EUS-FNA cytology was benign and the lesion remained < 1 cm from its original size on follow-up computed tomography (CT), magnetic resonance imaging or repeat EUS ≥ 6 mo after EUS-FNA; or (2) subsequent adrenalectomy and surgical pathology was benign. Ninety-four patients had left (n = 90) and/or right (n = 5) adrenal EUS-FNA without adverse events. EUS indications included: cancer staging or suspected recurrence (n = 31), pancreatic (n = 20), mediastinal (n = 10), adrenal (n = 7), lung (n = 7) mass or other indication (n = 19). Diagnoses after adrenal EUS-FNA included metastatic lung (n = 10), esophageal (n= 5), colon (n = 2), or other cancer (n = 8); benign primary adrenal mass or benign tissue (n = 60); or was non-diagnostic (n = 9). Available follow-up confirmed a benign lesion in 5/9 non-diagnostic aspirates and 32/60 benign aspirates. Four of the 60 benign aspirates were later confirmed as malignant by repeat biopsy, follow-up CT, or adrenalectomy. Adrenal EUS-FNA diagnosed metastatic cancer in 24, and ruled out metastasis in 10 patients. For the diagnosis of malignancy, EUS-FNA of either adrenal had sensitivity, specificity, positive predictive value and negative predictive value of 86%, 97%, 96% and 89%, respectively. Adrenal gland EUS-FNA is safe, minimally invasive and a sensitive technique with significant impact in the management of adrenal gland mass or enlargement.

The role of apparent diffusion coefficient values in differentiation between adrenal masses

The aim of this study was to evaluate the utility of apparent diffusion coefficient (ADC) values in differentiation between solid adrenal masses. The ADC values of 73 adrenal lesions (54 benign, 19 malignant) in 69 patients were measured at b 100, 600 and 1000 gradients on diffusion-weighted magnetic resonance imaging (DW-MRI). No statistically significant difference was found between ADC values of benign and malignant adrenal masses, nonadenomatous benign adrenal masses and malignant adrenal masses, adrenal adenomas and nonadenomatous lesions, adenomas and metastases, adenomas and pheochromocytomas, metastases and pheochromocytomas. ADC values are not helpful in the differentiation between solid adrenal masses.

Clinical Characteristics for 348 Patients with Adrenal Incidentaloma

BackgroundAdrenal incidentaloma is an adrenal neoplasm frequently encountered in clinical practice for which detection rates have recently increased. We describe here the clinical characteristics of adrenal incidentalomas.MethodsA retrospective study was performed examining the age, sex, location, size, function, and the histological findings for 348 patients with an adrenal mass discovered incidentally on computed tomography (CT) undertaken for health examination or nonadrenal disease from August 2005 to May 2012.ResultsPatients consisted of 156 males (44.8%) and 192 females (55.2%), aged between 20 and 86. Adrenal masses were most commonly found in patients in their sixth decade (32.5%). Regarding the location of the masses, 62.0% were found in the left adrenal gland, 30.2% were found in the right, and 7.8% were found bilaterally. Of all of the masses analyzed, 87.1% were 1 to 4 cm in size, and an adenoma-like appearance was the most common finding (75.3%) seen on CT scans. Hormonal analysis showed that 82.2% of the masses were nonfunctioning, 6.0% were diagnosed as subclinical Cushing's syndrome, 4.6% were aldosterone-producing adenomas, and 7.2% were pheochromocytomas. Adrenalectomy was performed in a total of 69 patients having adenoma (50.7%), pheochromocytoma (24.6%), and carcinoma (4.3%).ConclusionThe characteristics of benign, malignant, nonfunctional, and functional adrenal masses that were incidentally found at our hospital were similar to those presented in other studies.

How to approach and follow adrenal incidentaloma?

See Article on Page 557-564 Adrenal incidentaloma is defined as a previously unsuspected mass ≥ 1 cm in diameter, discovered incidentally during an imaging investigation for a nonadrenal disorder. It is frequently diagnosed, and its prevalence is 1% to 5% in different studies [1]. Advanced imaging techniques and the increased quality of medical services have resulted in more examinations using computed tomography (CT) or magnetic resonance imaging (MRI). Common causes of adrenal incidentaloma may be different according to the ethnicity of the study population. Most studies have shown that a nonfunctioning adenoma is the most frequent cause (60% to 85%) followed by subclinical Cushing syndrome, pheochromocytoma, and adrenal carcinoma; then there are other benign tumors, such as myelolipoma and metastasis, which are rare [2-4]. No consensus exists on the optimal diagnostic approach to adrenal incidentaloma. A report from the National Institutes of Health at a science conference and a review from an experienced clinician both recommended a hormonal evaluation. The diagnostic approach in patients with adrenal incidentalomas should focus on two main questions: 1) whether the lesion is malignant; and 2) whether it is hormonally active [5,6]. A low dose (1 mg) dexamethasone suppression test, providing sensitivity of 98.1% and specificity of 80.5% to 98.9%, is the mainstay biochemical screening test for detecting subclinical Cushing syndrome. A normal result is defined as a cortisol value 20 needs to be further evaluated for aldosterone hypersecretion. A radiological evaluation including noncontrast CT attenuation values expressed in Hounsfield units (HU) is the best tool for distinguishing between benign and malignant adrenal masses. All adrenal tumors with suspicious radiological features, most functional tumors, and all tumors > 4 cm in size that lack characteristic benign imaging features should be removed. All patients should undergo a hormonal evaluation for subclinical Cushing syndrome and pheochromocytoma, and those with hypertension should also be evaluated for primary hyperaldosteronism. One report demonstrated that the cumulative risk of developing endocrine abnormalities is 17% at 1 year, 29% at 2 years, and 47% at 5 years. The risk was high in the first 2 years of follow-up for an initial tumor diameter > 3 cm. The cumulative risk of mass enlargement was 6% at 1 year, 14% at 2 years, and 29% at 5 years, and it was greater in patients with normal adrenal function than in those with subtle hormonal abnormalities [1]. Limited data are available on the possible increase in adrenal mass size and hormonal pattern changes over time according to race or ethnicity. Only one prospective study has been reported in Korean patients with adrenal incidentaloma. Kim et al. [4] observed 24 patients with nonfunctioning adrenal incidentaloma for 3 to 72 months. Among them, two patients had increased tumor size of > 1 cm, and one patient developed Cushing syndrome at 10 to 26 months after the initial diagnosis. In this issue of The Korean Journal of Internal Medicine, Cho et al. [7] observed the clinical characteristics and the 2-year follow-up findings of patients with adrenal incidentaloma. In that study, 282 patients with adrenal incidentaloma were observed. Among them, 86.2% had a nonfunctioning mass, and 13.8% had a functioning mass; 9.9% were subclinical Cushing syndrome; 2.1% pheochromocytoma; and 1.8% primary aldosteronism. During the 22.5 months of follow-up of patients with nonfunctioning tumors, 4.2% developed functioning masses, pheochromocytoma, or subclinical Cushing syndrome. According to the recent experts' opinion, in most patients with an adrenal incidentaloma, particularly if the tumor is > 3 cm in size, annual biochemical follow-up for up to 5 years may be reasonable. Patients with adrenal masses 10 HU should have a repeat CT study in 3 to 6 months and then yearly for 2 years. Adrenal tumors with indeterminate radiological features that grow at least 0.8 cm over 3 to 12 months should be considered for surgical resection [3,8]. In summary, adrenal incidentaloma is a common clinical problem, and the diagnostic challenge is to distinguish the majority of benign lesions from other masses, as either malignant or hormone secreting, which require further treatment. An imaging evaluation (CT and MRI) is the key tool to distinguish malignant from benign lesions. All patients should be tested for hypercortisolism and pheochromocytoma, whereas hypertensive patients should only be tested for aldosteronism. Adrenalectomy should be considered for patients with adenoma with or without subclinical hypercortisolism during follow-up with clinical signs of hormone excess or clinical worsening despite optimal medical treatment. Even though there is no standardized international guidelines for the follow-up of endocrine and imaging tests, most experts recommend that hormonal observations should be performed annually for up to 4 to 5 years, an imaging evaluation at 3 to 6 months, and then annually for 1 to 2 years [9,10].

Laparoscopic Adrenalectomy: Retroperitoneal Approach

Laparoscopic adrenalectomy has become the gold standard for removal of benign adrenal masses. Despite initial concerns about safety, a long learning curve, and unfamiliarity of anatomy from the posterior approach, the posterior retroperitoneoscopic approach is now the preferred technique at many institutions, and offers several advantages over the transperitoneal approach, including direct access to the adrenal gland, avoiding negotiating scar tissue from previous abdominal operations, and allowing for bilateral surgery without patient repositioning. This review outlines the operative technique, indications and precautions for the posterior retroperitoneoscopic adrenalectomy.

Value of combined CT parameters in distinguishing benign from malignant adrenal masses in cancer patients

The aim of this work was to evaluate the effectiveness of combined CT parameters in distinguishing benign from malignant adrenal masses in cancer patients.The study included 33 patients with 39 adrenal masses. CT protocol included pre-contrast scan, dynamic and delayed contrast-enhanced scans assessing the mass size, pre-contrast attenuation, histogram & post-contrast absolute percentage washout (APW). Sensitivities, specificities, accuracies &P-values were calculated for individual and combined parameters.Adrenal masses included 13 lipid rich, nine lipid poor adenomas, one carcinoma and 16 metastases. Size was accurate in the differentiation of 26 of the total 39 masses (66.7%). Accuracy (82.05%) & specificity (68.18%) for the 10% negative pixels threshold on histogram were higher as compared to 76.9% & 59% for the 10 HU mean attenuation threshold. Using APW of 55% at 10min delay, a sensitivity of 88.23%, a specificity of 86.36% & an accuracy of 87.17% were calculated. The combination of pre-contrast attenuation & histogram values and the APW were highly significant for the differentiation of benign & malignant adrenal masses (P-value is <0.001).Combining the CT parameters including the pre-contrast attenuation values, histogram & the post-contrast washout analysis yielded a powerful diagnostic protocol with 74.3% accuracy, excluding the size parameter.

LAPAROSCOPY Laparoscopic adrenalectomy – ten-year experience

ObjectivesThe objective of the study is to summarize the authors’ 10-year experience with laparoscopic adrenalectomy and to analyze the intra- and postoperative complications of the procedure.Material and methodsThe records of 80 patients who had undergone laparoscopic adrenalectomy from January 2002 to January 2012 were reviewed retrospectively. There were 51 female and 29 male patients. The average age was 52. In 33 cases the right adrenal gland was affected, in 47 it was the left adrenal gland. Nineteen operations were performed with the retroperitoneal approach, in 61 a transperitoneal access was used. The average size of the tumor was 5 cm. The diagnosis was based on ultrasonography (USG) and computed tomography (CT). The biochemical tests were performed in all cases to assess hormonal activity of the tumor. Pheochromocytoma was diagnosed in 16 cases, Cushing syndrome in 3 cases, and Conn syndrome in 4 cases. All other tumors were hormonally inactive. Six patients were operated on because of adrenal metastases – from renal carcinoma in five cases and from lung carcinoma in one case.ResultsThere were three open conversions. The mean operative time was 158 minutes. The mean hospital stay was 5.5 days Blood transfusion was necessary in three patients. Postoperative complications were observed in 11 patients (13.7%).ConclusionsLaparoscopic adrenalectomy is a safe and effective procedure and should be considered the first – line treatment of benign adrenal masses. Our experience indicates that patients with adrenal metastases are suitable candidates for laparoscopic adrenalectomy, providing a skilled laparoscopic surgeon is involved in operation.

EUS FNA of Altered Left Adrenal Gland Morphology Suggests Amending CT and PET-CT Attenuation Threshold Values That Predict Malignancy

Introduction: In the setting of an extra-adrenal malignancy, it is a recognized clinical challenge to try and distinguish a benign adrenal mass from a metastatic deposit. Current non-invasive diagnostic tools for adrenal gland evaluation include CT, MRI, PET and PET-CT. Diagnostic interpretative error can occur as evaluations rarely have complete cytologic or histologic correlation for concordance purposes. Aims: To establish the performance characteristics of non-contrast CT attenuation values (Hounsfield units-HU) and the optimal PET-CT maximum standard uptake value (SUVmax) for predicting adrenal malignancy when correlated with adrenal gland endoscopic ultrasound fine needle aspiration (EUS FNA) cytology results. Methods: A prospectively maintained EUS database was reviewed to identify consecutive patients who underwent a left adrenal gland FNA. Non-contrast CT attenuation values and SUVmax scores were calculated. EUS FNA cytology results were used as the reference standard for determining the presence of benign versus malignant adrenal gland status. Results: Sixty-two patients (69 ± 11 years) underwent adrenal EUS FNA, 34 (54.8%) of whom had a clinically suspected or established extra-adrenal malignancy. Non-invasive imaging was suggestive of abnormal adrenal morphology or altered PET-CT FDG activity in 45 (72.6%) patients. Elevated attenuation values (≥10 HU) by non-enhanced CT had a sensitivity and specificity of 100% and 34.6%, respectively. The SUVmax for malignant altered morphology was significantly higher than that for benign lesions [(8.5 ± 3.1 vs 3.3 ± 0.7; (p = 0.0001)]. ROC curve analysis indicated that an optimum cutoff SUVmax of ≥4.1 (AUC 0.92) yielded the best power distinction for malignancy with a sensitivity and specificity of 89% and 100%. Conclusion: When evaluating altered adrenal morphology by non-invasive methods, the performance characteristics of elevated CT attenuation values are suboptimal. But by adopting a SUVmax cut-off value of ≥4.1 could potentially improve such characteristics to detect malignancy.

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 in Giant Masses

Laparoscopic adrenalectomy is considered the treatment of choice in the surgical management of the most majority of the adrenal diseases. Nevertheless, one of the much discussed topics is the dimensional cut-off for the laparoscopic treatment and it is not clear if laparoscopy should be used in large adrenal masses.Introduction. Laparoscopic adrenalectomy is the goal standard in benign adrenal masses smaller than 6 cm, while its advantages in masses larger than this cut-off and in malignant lesions is still discussed. We present six cases of laparoscopic adrenalectomy since November 2008 for masses between 7 and 15 cm; 4 men and 2 women. 3 right and 3 left. A complete adrenal endocrinological evaluation demonstrated that the lesions were not secreting tumors. All patients were studied with CT scan.The technique was performed using a flank approach with a 45° tilt. We used 5 trocars in patients who had the masses on the right side, and 4 in those who had the lesions on the left side. After creating an adequate pneumoperitoneum through an open access, the posterior peritoneum cutting, mobilization of the colon, medial dissection of the adrenal gland, and ligation of the main adrenal vein were performed. The adrenal gland was carefully dissected by Ultracision. The mass was extracted by endobag through an additional subcostal port. The mean operative time was 120 minutes. Blood loss was about 50 cc. The drainage was removed on day 2 after surgery and the patient was discharged on day 3. No postoperative complication occurred. The anatomopathologic exam gave evidence of myelolipoma and hemorrhagic cyst. The benefits of the laparoscopic approach are widely demonstrated and consist of a shorter hospital stay, reduced morbility, decreased analgesic requirement, and reduced intraoperative blood loss. One of the most discussed topics is the dimensional cut-off and it is not clear if the laparoscopy approach should be used in large adrenal masses (considering the longer operative time and increasing blood loss). Many surgeons performed laparoscopic adrenalectomy for masses of up to 13 cm, thus demonstrating that this procedure is safe and effective. A limitation of laparoscopic approach for adrenal giant masses is the increased risk to treat an adrenal cortical carcinoma. Our experience, supported by the literature, demonstrates that the laparoscopic adrenalectomy is a feasible and effective surgical technique also in the case of giant masses. Preoperative diagnosis has a predominant role to determine the contraindication of this technique (invasive adrenal carcinoma).

Differentiation between Benign and Malignant Adrenal Mass using Contrast-Enhanced Ultrasound

Adrenal masses can be detected by ultrasound with high sensitivity and specificity. The aim of the present study was to evaluate CEUS in a large patient population using CEUS patterns identified in a previous pilot study. 116 adrenal masses were evaluated by ultrasound, including CEUS with the contrast agent Sonovue®. The dynamic of contrast enhancement (CE) was analyzed using time-intensity curves. The time of the first CE in the adrenal mass was used to define four CEUS patterns: pattern I = early arterial CE, pattern II = arterial CE, pattern III = late CE, pattern IV = no CE. In addition, all patients received CT/MRI and hormonal testing. In suspicious cases biopsy or adrenalectomy was performed. CEUS patterns I&II were seen in all patients with primary or secondary malignant lesions of the adrenal gland (n = 16). The sensitivity and specificity of CEUS for the diagnosis of malignant adrenal mass were 100 % (CI [75;100]) and 67 % (CI [56;75]), respectively. Overall histology was available as a reference method for 40 adrenal masses. In 68 % of histologically diagnosed adrenal masses, MRI/CT and CEUS were congruent concerning the characterization of malignant versus benign adrenal mass. Contrast-enhanced ultrasound may be a useful method in the diagnostic work-up of adrenal mass with excellent sensitivity for the diagnosis of malignancy.

Medical and Surgical Evaluation and Treatment of Adrenal Incidentalomas

Adrenal incidentalomas are detected in approximately 4% of patients undergoing high-resolution abdominal imaging studies. The majority of adrenal incidentalomas are benign, but careful evaluation of all patients is warranted to be certain that primary adrenocortical carcinoma and functional adenomas are not missed. The diagnostic approach in patients with adrenal incidentalomas should focus on two main questions: whether the lesion is malignant, and whether it is hormonally active. Radiological evaluation including noncontrast and contrast computed tomography attenuation values expressed in Hounsfield units is the best tool to differentiate between benign and malignant adrenal masses. All adrenal tumors with suspicious radiological findings, most functional tumors, and all tumors more than 4 cm in size that lack characteristic benign imaging features should be surgically excised. All patients should undergo hormonal evaluation for subclinical Cushing's syndrome and pheochromocytoma, and those with hypertension should also be evaluated for hyperaldosteronism. Combined 1-mg dexamethasone suppression test, plasma metanephrines, and aldosterone/plasma renin activity measurements (if hypertensive) are reasonable initial hormonal evaluations. Annual biochemical follow-up of most patients with adrenal incidentalomas, especially if the tumor is more than 3 cm in size, for up to 5 yr may be reasonable. Patients with adrenal masses less than 4 cm in size and a noncontrast attenuation value of more than 10 Hounsfield units should have a repeat computed tomography study in 3-6 months and then yearly for 2 yr. Adrenal tumors with indeterminate radiological features that grow to at least 0.8 cm over 3-12 months may be considered for surgical resection.

Laparoscopic adrenalectomy in urological centres – the experience of the German Laparoscopic Working Group

To evaluate the safety and feasibility of laparoscopic adrenalectomy (LA) performed in several German centres with different laparoscopic experience, as LA has become the gold-standard approach for benign surgical adrenal disorders; however, for solitary metastasis or primary adrenal cancer its precise role is uncertain. The data of 363 patients who underwent a LA were prospectively collected in 23 centres. All centres were stratified into three groups according to their experience: group A (<10 LAs/year), group B (10-20 LAs/year) and group C (>20 LAs/year). In all, 15 centres used a transperitoneal approach, four a retroperitoneal approach and four both approaches. Demographic data, perioperative and postoperative variables, including operating time, surgical approach, tumour size, estimated blood loss, complications, hospital stay and histological tumour staging, were collected and analysed. The transperitoneal approach was used in 281 cases (77.4%) and the retroperitoneal approach was used in 82 patients (22.6%). In all, 263 of 363 lesions (72.5%) were benign and 100 (27.5%) were malignant. The mean (sd) operating time was 127.22 (55.56) min and 130.16 (49.88) min after transperitoneal and retroperitoneal LA, respectively. The mean complication rates for transperitoneal and retroperitoneal LA were 5% and 10.9%, respectively. LAs performed by urologists experienced in laparoscopy is safe for the removal of benign and malignant adrenal masses. LA for malignant adrenal tumours should be performed only in high-volume centres by a surgeon performing at least >10 LAs/year.

Is Laparoscopy Contraindicated in Giant Adrenal Masses?

The first laparoscopic adrenalectomy was performed and described by Gagner in 1992. Since then, this technique has become more and more widespread and there is common agreement in the literature that it is the gold standard for adrenalectomy. Laparoscopic adrenalectomy is indicated in benign adrenal masses, and it is routinely performed in masses smaller than 5 to 7 cm. The laparoscopic procedure in masses larger than this cut-off is discussed, although many investigators agree about its feasibility, safety and effectiveness. We present this case: man, 39 years old, large palpable mass in the right hypochondrium. Computed tomography scan (CT) suggested the diagnosis of giant adrenal myelolipoma (15x12x7 cm). Complete adrenal endoclinologic evaluation showed that the lesion was not a secreting tumor. Laparoscopic adrenalectomy was performed with good results.

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.

Incidental Non-Secreting Adrenal Masses in Cancer Patients: Intra-Individual Comparison of 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography with Computed Tomography and Shift Magnetic Resonance Imaging

The ability of integrated (18)F-fluorodeoxyglucose positron emission tomography and computed tomography (FDG PET/CT) to distinguish between benign and malignant incidental non-secreting adrenal masses was evaluated in cancer patients. Results were compared with those of CT and shift magnetic resonance imaging (MRI). A total of 1832 cancer patients who had undergone FDG PET/CT scans were retrospectively evaluated. Visual interpretation, tumour maximum standardized uptake value (SUV(max)), liver SUV(max) and tumour/liver SUV(max) ratios were correlated with the findings of CT, shift MRI and final diagnosis (based on biopsy or clinical/radiological follow-up). A total of 109 adrenal masses were found: 49 were malignant and 60 were benign on final diagnosis. A tumour/liver SUV(max) ratio threshold of 1.0 was more accurate in differentiating the tumour type than tumour SUV(max) or visual interpretation alone. Diagnostic accuracy of CT and shift MRI (92 - 97%) was similar to that for FDG PET/CT (94 - 97%). In conclusion, FDG PET/CT accurately characterizes adrenal tumours, with excellent sensitivity and specificity. Use of 1.0 as the threshold for the tumour/liver SUV(max) ratio seems to be promising for distinguishing benign from malignant adrenal masses in cancer patients.

V765 LAPAROSCOPIC ADRENALECTOMY FOR PHEOCHROMOCYTOMA ASSOCIATED WITH HORSESHOE KIDNEY

You have accessJournal of UrologyOncology (TCC & Adrenal) & Teaching Techniques1 Apr 2010V765 LAPAROSCOPIC ADRENALECTOMY FOR PHEOCHROMOCYTOMA ASSOCIATED WITH HORSESHOE KIDNEY Thomas Christiano, Nitin Patel, Jennifer Yates, Jayant Uberoi, and Ravi Munver Thomas ChristianoThomas Christiano More articles by this author , Nitin PatelNitin Patel More articles by this author , Jennifer YatesJennifer Yates More articles by this author , Jayant UberoiJayant Uberoi More articles by this author , and Ravi MunverRavi Munver More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1359AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Adrenal pheochromocytoma is associated with various genetic syndromes including multiple endocrine neoplasia and neurofibromatosis type 1 (NF-1). Patients with NF-1 are more likely to have renal anomalies including a horseshoe kidney. Laparoscopic adrenalectomy is the standard technique for the surgical removal of benign adrenal masses, including pheochromocytoma. This video illustrates the excision of a right adrenal pheochromocytoma in a patient with neurofibromatosis and a horseshoe kidney. METHODS A 62 year old female with NF-1 was referred for a diagnosis of a right adrenal mass. Radiographic characteristics and endocrinologic evaluation revealed the mass to be consistent with a pheochromocytoma in the setting of a horseshoe kidney. The patient elected surgical management via a laparoscopic approach. Appropriate preoperative medical management was instituted. RESULTS A transperitoneal approach was employed with the use of 4 trocars, including three 5 mm trocars and one 12 mm trocar. The procedure began with extensive mobilization of the liver. An upper pole renal artery and vein were noted to be in close proximity to the inferior border of the adrenal gland as they coursed to the kidney from a cephalad direction. Meticulous dissection resulted in identification of the inferior vena cava and a large hepatic vein. Further dissection revealed an anomalous main adrenal vein that drained into the hepatic vein. The adrenal vein was dissected, ligated with clips, and transected with a bipolar vessel-sealing device. The upper, lateral, and inferior attachments of the adrenal gland were dissected from surrounding structures and the adrenal gland was placed into a laparoscopic bag and extracted. The operative time was 104 minutes and blood loss was 5 milliliters. The patient was discharged home on the first postoperative day without complication. Final pathology revealed a 3.5 cm pheochromocytoma. CONCLUSIONS Laparoscopic adrenalectomy in the setting of a horseshoe kidney may be complicated by anomalous anatomy. In particular, anomalies or multiplicity of the adrenal vessels or renal hilar vessels must be suspected. Cautious dissection and recognition of potential abnormalities can result in successful minimally-invasive removal of the adrenal gland in patients with horseshoe kidneys. Hackensack, NJ© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e299 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Thomas Christiano More articles by this author Nitin Patel More articles by this author Jennifer Yates More articles by this author Jayant Uberoi More articles by this author Ravi Munver More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

A large single-center experience of EUS-guided FNA of the left and right adrenal glands: diagnostic utility and impact on patient management

EUS-guided FNA of the left and right adrenals has been described, but data are very limited. Our primary objective was to determine the impact of the diagnostic utility of EUS-guided FNA of adrenal glands on patient management. Our secondary objective was to determine predictors of malignant adrenal involvement. Observational study. Tertiary referral center. Patients with enlarged adrenal(s) on abdominal imaging underwent EUS-guided FNA. The left adrenal (n = 54) was sampled via the transgastric approach and the right adrenal (n = 5) via a transduodenal approach. Fifty-nine patients (63% men, median age 65 years) were evaluated. The median adrenal gland size was 25 x 17 mm. Adrenal tissue adequate for interpretation was obtained in all of the patients. EUS-guided FNA confirmed malignancy in 22 (37%) patients. Based on size (> or =30 mm) alone, EUS had an accuracy of 68%. Patients with malignant cytology had higher standard uptake value scores on positron-emission tomography compared with patients with benign adrenal masses (P < .001). Malignant masses were more likely to have an altered adrenal gland shape compared with benign masses (crude odds ratio [OR] 12.0; P < .001). On multivariable analysis, altered adrenal gland shape was a significant predictor of malignancy (adjusted OR 7.94; P = .015), whereas a size of 30 mm or larger (adjusted OR 1.30; P = .774) and hypoechoic nature (adjusted OR 12.05; P = .148) were not. All patients except 2 with malignant cytology were treated with systemic therapy without the need for additional invasive biopsies or surgery. No immediate complications were encountered. Lack of surgical criterion standard; 1 experienced endosonographer. EUS-guided FNA of the adrenal glands is a minimally invasive and safe approach that documents or excludes malignant involvement. EUS-guided FNA should be the first next test to evaluate enlarged adrenal glands because it directs therapy and affects patient management.