Large Adrenal Tumors Research Articles

Adrenal tumour bigger than 5 cm - what could it be? An analysis of 139 cases.

There is an increasing number of adrenal being tumours discovered incidentally during imaging examinations performed for many different indications. Radiological findings suggesting adrenal pathology may be caused by true adrenal tumours or by other retroperitoneal masses. Generally, the larger the tumour, the higher the possibility of adrenal cancer. Analysis of our data - 139 operations performed over 11 years (2004-2014) in patients with tumours in the adrenal area larger than 5 cm. The most common finding was adrenal cancer (25.2%), benign adenoma (24.5%), pheochromocytoma (12.9%), and metastatic cancer (10.1%). In total, there were 19 various histopathological diagnoses in this group. Although adrenal cancer is the most likely diagnosis in large adrenal tumours, a broad spectrum of various adrenal and retroperitoneal tumours with size more than 5 cm can be found in such patients.

Experience of 243 cases in transperitoneal robotic-assisted laparoscopic surgery for adrenal diseases

Objective To summarize our experience in robotic-assisted laparoscopic surgery for adrenal diseases Methods The clinical data of 243 patients with adrenal tumor treated by robotic-assisted laparoscopic surgery from March 2010 to February 2017 were retrospectively reviewed. There were 99 men and 144 women. The mean age was 51.6 years (range, 19-84). Tumors located at left adrenal in 140 cases , right in 97 cases, and both sides in 6 cases. The average diameter was 3.32 cm (range, 0.8-12 cm). However, there were 41 cases whose tumor diameter were greater than 5 cm. Results There were 2 cases of conversion during operation, 1 case converted to open surgery and the other to the traditional laparoscope surgery. The mean operative time was 35 min (range, 20-130 min). Estimated blood loss was 80 ml (range, 20-1 200 ml). Blood transfusion was needed in 6 cases. The mean postoperative hospital stay was 5d (range, 3-20 d). The pathological diagnosis included 37 cases of pheochromocytoma, 149 cases of cortical adenoma, 3 cases of cortical carcinoma, 5 cases of metastatic tumor, 9 cases of adrenal myelolipoma, 3 cases of adrenal cyst, 2 cases of bronchogenic cyst, 25 cases of adrenal nodular hyperplasia, 2 cases of angiomyolipomas, 1 case of mature teratoma, 1case of diffuse large B-Cell lymphoma, 1 case of angioma, and 4 cases of neurofibromatosis. Conclusions Robotic-assisted laparoscopic adrenalectomy was safe and effective. Robotic-assisted laparoscopic surgery has the advantages over laparoscopic surgery in treatment of complicated adrenal tumor, such as large adrenal tumors, pheochromocytoma, bilateral adrenal diseases, overweight and obese patients with adrenal diseases. Key words: Adrenal tumor; Robotic; Laparoscopic; Adrenalectomy

Adrenal Teratoma: Unusual Tumor with Typical Imaging Characteristics

ABSTRACT Teratomas per se are rare and retroperitoneal teratomas are a still rarer entity. We report the image of a patient who presented with a large adrenal teratoma which was nonfunctional biochemically and who underwent surgical excision. The imaging characteristics are suggestive of teratoma and must be kept in mind while managing large adrenal tumors. How to cite this article Ramakant P, Singh KR, Mishra AK. Adrenal Teratoma: Unusual Tumor with Typical Imaging Characteristics. World J Endoc Surg 2017;9(2):78.

Laparoscopic Adrenalectomy for Adrenal Tumor Larger than 5 cm

Objective The adrenal gland is small and located in difficult area to approach, anatomically. Laparoscopic adrenalectomy (LA) is considered as a best approach for the treatment for adrenal tumors. However, its role in removal of larger tumor (>5 cm) is still questioned due to concerns of complexity of procedure. We evaluate technical feasibility and analyze the outcome of LA for large adrenal masses. Methods The data of 36 patients who underwent LA for adrenal mass were analyzed for this study. Group 1 (n=27, mean diameter= 2.43 cm) consisted of tumors smaller than 5 cm and group 2 (n=9, mean diameter=5.64 cm) consisted of larger than 5 cm. The length of operation time, estimated blood loss, analgesics usage, length of hospital stay, histopathology, tumor size, and perioperative complications were compared. Results All operation was completed safely and no one required conversion to open surgery. Group 1 (146.48 minutes) had a significantly shorter mean operative time compared to group 2 (181.00 minutes) (P<0.05). There was no significant difference in the postoperative hospital stay, time to remove the drainage, estimated blood loss, and the number of analgesics usage. No major complication was occurred during and after operation but one case of pulmonary congestion was occurred in group 2. Histopathologic findings were 20 cortical adenomas (55.6%), 3 cystic lesions (8.3%), and 3 malignant lesions (8.3%). Conclusion LA is safe and feasible for large adrenal tumors without local invasion. The size of an adrenal tumor should not be the primary factor in determining whether a LA should be performed. Key words: Laparoscopy; Adrenalectomy; Adrenal glands

Refractory hypoglycemia in a patient with functional adrenal cortical carcinoma.

SummaryAdrenacarcinomas are rare, and hypoglycemic syndrome resulting from the secretion of insulin-like growth factor II (IGF-II) by these tumors have been described infrequently. This study describes the case of a young woman with severe persistent hypoglycemia and a large adrenal tumor and discusses the physiopathological mechanisms involved in hypoglycemia. The case is described as a 21-year-old woman who presented with 8 months of general symptoms and, in the preceding 3 months, with episodes of mental confusion and visual blurring secondary to hypoglycemia. A functional assessment of the adrenal cortex revealed ACTH-independent hypercortisolism and hyperandrogenism. Hypoglycemia, hypoinsulinemia, low C-peptide and no ketones were also detected. An evaluation of the GH–IGF axis revealed GH blockade (0.03; reference: up to 4.4 ng/mL), greatly reduced IGF-I levels (9.0 ng/mL; reference: 180–780 ng/mL), slightly reduced IGF-II levels (197 ng/mL; reference: 267–616 ng/mL) and an elevated IGF-II/IGF-I ratio (21.9; reference: ~3). CT scan revealed a large expansive mass in the right adrenal gland and pulmonary and liver metastases. During hospitalization, the patient experienced frequent difficult-to-control hypoglycemia and hypokalemia episodes. Octreotide was ineffective in controlling hypoglycemia. Due to unresectability, chemotherapy was tried, but after 3 months, the patient’s condition worsened and progressed to death. In conclusion, our patient presented with a functional adrenal cortical carcinoma, with hyperandrogenism associated with hypoinsulinemic hypoglycemia and blockage of the GH–IGF-I axis. Patient’s data suggested a diagnosis of hypoglycemia induced by an IGF-II or a large IGF-II-producing tumor (low levels of GH, greatly decreased IGF-I, slightly decreased IGF-II and an elevated IGF-II/IGF-I ratio).Learning points:Hypoglycemyndrome resulting from the secretion of insulin-like growth factor II (IGF-II) by adrenal tumors is a rare condition.Hypoinsulinemic hypoglycemia associated with hyperandrogenism and blockage of the GH–IGF-I axis suggests hypoglycemia induced by an IGF-II or a large IGF-II-producing tumor.Hypoglycemia in cases of NICTH should be treated with glucocorticoids, glucagon, somatostatin analogs and hGH.

International Consultation on Urological Diseases and European Association of Urology International Consultation on Minimally Invasive Surgery in Urology: laparoscopic and robotic adrenalectomy.

The aim of this study was to provide an evidence-based systematic review of the use of laparoscopic and robotic adrenalectomy in the treatment of adrenal disease as part of the International Consultation on Urological Diseases and European Association of Urology consultation on Minimally Invasive Surgery in Urology. A systematic literature search (January 2004 to January 2014) was conducted to identify comparative studies assessing the safety and efficacy of minimally invasive adrenal surgery. Subtopics including the role of minimally invasive surgery for pheochromocytoma, adrenocortical carcinoma (ACC) and large adrenal tumours were examined. Additionally, the role of transperitoneal and retroperitoneal approaches, as well as laparoendoscopic single-site (LESS) and robotic adrenalectomy were reviewed. The major findings are presented in an evidence-based fashion. Large retrospective and prospective data were analysed and a set of recommendations provided by the committee was produced. Laparoscopic surgery should be considered the first-line therapy for benign adrenal masses requiring surgical resection and for patients with pheochromocytoma. While a laparoscopic approach may be feasible for selected cases of ACC without adjacent organ involvement, an open surgical approach remains the 'gold standard'. Large adrenal tumours without preoperative or intra-operative suspicion of ACC may be safely resected via a laparoscopic approach. Both transperitoneal and retroperitoneal approaches to laparoscopic adrenalectomy are safe. The approach should be chosen based on surgeon training and experience. LESS and robotic adrenalectomy should be considered as alternatives to laparoscopic adrenalectomy but require further study.

Techniques to perform robotic left adrenalectomy in the obese patient.

Minimally invasive adrenalectomy may be associated with reduction in postoperative pain, morbidity, and length of stay and, as a result, has become a preferred approach for many adrenal tumors. Left-sided adrenal tumors, however, are particularly challenging to address in the morbidly obese patient due to difficulties in maintaining exposure and dissection. The robotic platform offers instruments with greater degrees of freedom that aid in retraction and dissection, especially of the adrenal vein, but fixed patient positioning and the large distance needed between patient ports to avoid arm collisions can be restrictive in patients with a large amount of retroperitoneal fat and small working space. We demonstrate robotic left adrenalectomy (RLA) in a consecutive series of patients with a mean weight of 99 kg and mean BMI of 36. Techniques to safely and efficiently perform RLA in obese patients are stepwise demonstrated, including (1) Patient positioning, (2) Management of the pannus, (3) Customized port placement, (4) Medial retraction of the pancreas, (5) Finding the left adrenal vein, and (6) Management of bleeding. Intraoperative videos from multiple patients also show surgical pitfalls, examples of poor port placement, arm collisions, alternative approaches to the vein, and techniques to control unexpected bleeding. All patients in the series underwent successful RLA with negative margins, no major intra- or postoperative complications, and discharge on POD 1-2. Though poor exposure due to patient body habitus is a relative contraindication, even large left-sided adrenal tumors can be safely approached robotically while adhering to oncologic principles, as is demonstrated in this video.

Feasibility and safety of laparoscopic adrenalectomy for large tumours

ObjectiveTo verify the feasibility and safety of laparoscopic adrenalectomy for large tumours, as since it was described, the laparoscopic approach for adrenalectomy has become the ‘gold standard’ for small tumours and for large and non-malignant adrenal tumours many studies have reported acceptable results. Patients and methodsThis is a retrospective study from a general surgery department from January 2006 to December 2013 including 45 patients (56 laparoscopic adrenalectomies). We divided patients into two groups according to tumour size: <5 or ⩾5cm, we compared demographic data and peri- and postoperative outcomes. ResultsThere was no statistical difference between the two groups for conversion rate (3.7% vs 11.7% P=0.32), postoperative complications (14% vs 12%, P=0.4), postoperative length of hospital stay (5 vs 6days P=0.43) or mortality (3.5% vs 0% P=0.99). The only statistical difference was the operating time, at a mean (SD) 155 (60) vs 247 (71) min (P<0.001). ConclusionLaparoscopic adrenalectomy for large tumours needs more time but appears to be safe and feasible when performed by experienced surgeons.

Teaching Laparoscopic Adrenalectomy to Surgical Residents.

Laparoscopic adrenalectomy is the surgical treatment for various adrenal diseases. The procedure is a common surgical practice for urologists and general surgeons and requires fundamental laparoscopic skills, nowadays common in the surgical education of residents in these practices. The aim of this study is to assess whether laparoscopic adrenalectomy differs in outcome between certified and trained surgeons and surgical residents and whether the learning curve changes the endpoint of the surgery. A cohort retrospective study, including all adult patients who underwent laparoscopic adrenalectomy between June 2008 and June 2014, was conducted. Patients' demographic, clinical, and surgical data were recorded and analyzed. Fifty-three patients were included in the database (21 men, 32 women) with a mean age of 54 years (range 17-77). The cause for surgery was most commonly a benign adrenal tumor (27 patients, 50.9%) followed by large nonfunctioning adrenal tumors (16 patients, 30.1%), and adrenal cancer (8 patients, 15%). Eighteen patients (33.9%) were operated by residents (4-6 years into the residency) and 35 patients by a certified senior surgeon (66.1%). Left-sided adrenalectomy was preferred to right-sided adrenalectomy for resident tutoring (P = .03). Overall, intraoperative complications were seen in 6 patients (11.3%) and postoperative complications were seen in 9 patients (16.9%). There were no differences in operation time (P = .36), intraoperative complications (P = .76), postoperative complications (P = .96), and length of stay (P = .34) between the patients operated by senior residents and certified surgeons. Laparoscopic adrenalectomy is a complex surgical procedure that should be a part of the surgical training of surgery residents, as it is safe in guided hands.

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

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. (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. 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 ≥5cm (N=50) and "small" tumours as <5cm (N=150). Further analysis adopting a ≥8cm (N=15) cut-off size was performed. 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 ≥5cm, 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 ≥8cm was associated with prolonged operative time (HR 0.47; 95% CI 0.24-0.94). 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 ≥8cm, and patient comorbidities have the largest impact on operative time and length of hospital stay in laparoscopic large adrenal tumour resection.

Laparoscopic adrenalectomy for large adrenal masses: Is it really more complicated?

Laparoscopic treatment of large adrenal tumors is still questionable due to concern over the risk of malignancy as well as the technical difficulties. No exact dimensional cut-off has been described for laparoscopic adrenalectomy (LA). In this study, we reviewed our experience with LA for masses ≥ 8 cm and tried to determine the limitations of this surgery in this group of patients. Sixteen patients with adrenal mass ≥ 8 cm (Group 1) and 19 patients with adrenal mass < 8 cm (Group 2) treated with transabdominal LA were included in this study. We analyzed operative time, intraoperative and postoperative complications and length of postoperative hospital stay with respect to tumor size and clinopathologic features. Mean maximum tumor diameters were 91.7 mm (range, 80–150 mm) and 52.4 mm (range, 35–73 mm) in Group 1 and Group 2, respectively. Operation time and blood loss were higher in Group 1 compared to Group 2, but these differences did not reach significant levels (p>0.05). Conversion to an open procedure required in two patients, one from each group, because of the firm attachments of adrenal mass to the surrounding tissue. In conclusion, our study demonstrated that LA is a safe and feasible procedure for large lesions even up to 15 cm. The risk of finding incidental adrenal cortical cancer was significantly increased for large lesions in our series as in the literature; therefore, it is important to follow the strict oncological principles in these cases.

Techniques to perform a laparoscopic right adrenalectomy for metastases abutting the liver, renal vein, and posterior vena cava.

Introduction Laparoscopic adrenalectomy (LA) may be associated with reduction in postoperative pain, morbidity, length of stay, and cost compared to open adrenalectomy, and, as a result, has become a preferred approach for benign tumors. Though recent series have reported safety and oncologic non-inferiority with a minimally invasive approach to malignant and metastatic adrenal tumors, relative contraindications to LA include malignancy, large size, and invasion or abutment of vital structures. We demonstrate techniques to perform LA in an obese patient with a large ([6 cm) solitary breast metastasis to the right adrenal gland that was adherent to the liver, inferior vena cava (IVC), and right renal vein. The tumor was growing behind the infrahepatic IVC and was abutting the confluence of the renal vein/IVC. The patient was monitored on systemic treatment with no new sites of disease and after achieving a maximal response to neoadjuvant treatment. Laparoscopic techniques to safely approach adrenal tumors adherent to the liver, IVC, and renal vein are stepwise demonstrated, including appropriate patient positioning and port site selection. The tumor was excised with negative margins, and the patient was discharged on postoperative day 1 with minimal pain medication and tolerating a regular diet. Though malignancy is a relative contraindication to LA, even large right-sided adrenal tumors abutting the liver and growing behind the IVC can be safely approached while adhering to oncologic principles, as is demonstrated in this video.

Adrenal Metastases from Thyroid Cancers: Three Personal Cases and Literature Review

Introduction : Adrenal glands are not a common site for thyroid cancer (TC) metastases. Our aim was to report three adrenal masses, which are likely to be metastases from aggressive thyroid cancers. Case Reports: Case1 : a woman aged 57 harboring an anaplastic TC staged T4b, N1b, M0, consulted for severe fatigue. Clinical examination noted skin hyper pigmentation and a large thyroid mass. Hormonal assessment showed adrenal insufficiency, thyroglobulin =1.4ng/ml. Radiological exploration demonstrated diffuse metastases with two large adrenal tumors (AT) which did not fix radioiodine. According to the context AT were likely to be metastases. She died one month later. Case 2 : a woman aged 56 was referred for oncocytic papillary TC with pulmonary and bone metastases. Thyroglobulin was 450ng/ml. Total body scan showed diffuse metastases with adrenal localizations. Those did not fix radioiodine. Adrenals’ fine nodule aspiration confirmed the thyroid origin. One year later, she is still alive, but with a profound degradation of her general condition. Case 3 : a 53 year-old woman was sent for a suspect thyroid nodule. Radiological explorations showed diffuse metastases, except for adrenals ones. After surgery, the papillary TC was confirmed (stage T4N1M1, thyroglobulin=450ng/ml). Some months later a right adrenal mass appeared. That one did not fix radioiodine. The patient died 2 years later. Conclusion : The three observations seem worth to be reported for their rarity and for the possible association to adrenal insufficiency. That one may worsen the poor prognosis as adrenal metastases are observed in aggressive forms.

Large testicular adrenal rest tumours in a patient with congenital adrenal hyperplasia.

SummaryTesticular adrenal rest tumours (TARTs) are benign ACTH-dependent tumours that occur in males with congenital adrenal hyperplasia (CAH) and if left untreated can destroy testicular tissue. Corticosteroid suppressive treatment could result in the regression of these testicular tumours. We present a patient with bilateral large TARTs as a consequence of poor compliance to treatment and follow-up for his CAH, who consequently had to have bilateral orchidectomies and prosthesis replacement.Learning points TARTs are frequently seen in males with CAH, and can be misdiagnosed as primary testicular cancer.Patient compliance to treatment and follow-up are necessary to reduce the risk of testicular damage as a result of TARTs in patients with CAH.Boys with CAH should have periodic ultrasonographic screening from before adolescent age for early detection of TARTs.Regular monitoring of renin, 17-hydroxyprogesterone and androgens levels is required to assess corticosteroid suppressive treatment.Patients with CAH should be offered psychological support and information concerning CAH support groups.

Neuroblastoma in Children Under 12 Months in Singapore—15-Year Experience and Outcomes From KKH

Background: Expectant observation of small adrenal lesions has shown promising results in recent studies. We present our 15 years outcome of managing infant neuroblastoma. Methods: All patients with neuroblastoma below the age of 1 year treated at the largest pediatric hospital in Singapore between 1998 and 2012 were identified. Results: Twenty-two patients were included in our study. Six were antenatally diagnosed. Nineteen (86%) patients had surgical resection of the tumor. Eight (36%) patients received chemotherapy as part of their treatment. Six patients were observed three of which had large adrenal tumors. Median follow-up in our series was 2.6 years. The 5 year overall survival was 90%. There were no recurrences and there were 2 deaths in our series. Conclusion: Our series shows excellent outcomes of infant neuroblastoma at our center. Careful observation of large tumors may be an option to avoid the morbidity of surgery.

Safety and feasibility of laparoscopic adrenalectomy: What is the role of tumour size? A single institution experience

BACKGROUND:Although, there are studies in the literature having shown the feasibility and safety of laparoscopic adrenalectomy, there are still debates for tumour size and the requirement of the minimal invasive approach. Our hypothesis was that the use of laparoscopy facilitates minimally invasive resection of large adrenal tumours regardless of tumour size.Materials and Methods:Within 7 years, 149 patients underwent laparoscopic adrenalectomy at one institution. The patients were divided into two study groups according to tumour size. Group 1 included patients with adrenal tumours smaller than 5 cm and group 2 included larger than 5 cm. Patient demographics and clinical parameters, operative time, complications, hospital stay and final pathology were analysed. Statistical analyses of clinical and perioperative parameters were performed using Student's t-test and Chi-square tests.RESULTS:There were 88 patients in group 1 and 70 in group 2. There were no significant differences between study groups regarding patient demographics, operative time, hospital stay, and complications. Estimated blood loss was significantly higher in group 2 (P = 0.002). The conversion to open rate was similar between study groups with 5.6% versus 4.2%, respectively. Pathology was similar between groups.CONCLUSION:Our study shows that the use laparoscopy for adrenal tumours larger than 5 cm is a safe and feasible technique. Laparoscopic adrenalectomy is our preferred minimally invasive surgical approach for removing large adrenal tumours.

De novo adrenal malignant peripheral nerve sheath tumor in a young female. An orphan disease

Tumors arising from the adrenal gland are not uncommon. Most of these are benign diseases. Most malignancies of the adrenal gland are carcinomas and usually diagnosed at an advanced stage with a guarded prognosis. Malignant Peripheral Nerve Sheath Tumor (MPNST) of the adrenal gland is an extremely rare pathology, mostly seen amongst patients with Von Recklinghausen’s disease. Only eight cases of MPNST of the adrenal gland have been reported in the literature till date with only one case reported to be arising De Novo. Differentiation of this entity from other tumors of the adrenal gland becomes imperative in view of the various diagnostic and therapeutic implications. Moreover, the tumor size and pattern of expression for certain immunohistochemical markers may serve as independent predictors of aggressiveness. Herein we present the case of a 14 years old female who presented with a large right adrenal gland malignant peripheral nerve sheath tumor. With the nature of clinical presentation of this tumor, it is easy for the surgeon to be confused with any other adrenal tumor that tends to be benign. Differentiation of this entity from other soft tissue sarcomas and gastrointestinal stromal tumor of the adrenal gland becomes imperative in view of various diagnostic and therapeutic implications.

Risk of adrenocortical carcinoma in adrenal tumours greater than 8 cm.

Adrenocortical cancer (ACC) is a rare malignancy. In the absence of metastatic disease, the suspicion of ACC is based on size and radiological appearance. The aim of this study was to analyse the long-term outcome of patients with large adrenal cortical tumours (>8 cm). A prospective database recorded clinical, biochemical, operative and histological data on patients operated for cortical adrenal tumours between January 2000 and February 2013. Out of 130 patients operated for cortical adrenal tumours, analysis was restricted to 37 cortical tumours >8 cm. There were 31 (84 %) ACCs and 6 (16 %) benign adenomas (p < 0.01). The most common presentation was that of an abdominal mass [17 (55 %) vs. 3 (50 %), ACC vs. benign, respectively]. There was no difference in size between stage II and stage III-IV tumours; however, there was a trend for tumours to be heavier in advanced stages (920 ± 756 vs. 1,435 ± 1,022 g, p = 0.08, stage II vs. stage III-IV, respectively). No mortality was observed in patients with benign tumours during a median follow-up of 70 months (range 36-99 months). Mortality in the ACC group occurred in 17/31 (55 %) patients. Mitotane was administered in 12 (71 %) patients with stage III-IV ACCs with a 5-year survival rate 25 % compared to 20 % in patients who did not receive Mitotane. In stage II ACC, eight (57 %) patients received Mitotane with a 50 % mortality at 5 years. The high incidence of ACC in cortical tumours >8 cm underlines the need for adequate surgical resection via open surgery aiming to avoid local recurrence. Beyond surgery, the impact of other therapies is not fully characterised and the efficacy of adjuvant Mitotane treatment is yet to be proven.

Catastrophic hemorrhage of adrenal pheochromocytoma following thrombolysis for acute myocardial infarction: case report and literature review

We describe here the case of a 62-year-old man with acute abdominal syndrome and severe hemorrhagic shock following successful thrombolysis for acute cardiac infarction. Emergency surgical exploration revealed extensive intraperitoneal and retroperitoneal hemorrhage resulting from the rupture of a large adrenal tumor. The diagnosis of pheochromocytoma was confirmed by histological findings. The patient died a few hours after surgery from multiorgan failure despite resuscitation attempts. This report discusses the diagnosis difficulties, treatment approach, and relevant literature.

Laparoscopic Adrenalectomy for Large Adrenal Tumors: Is the “Vein First” Really Worthwhile?

Abstract Introduction: The role of minimally invasive surgery for large adrenal tumors remains a highly controversial problem. Risks of inadequate margin resection, increased risk of early local recurrence, peritoneal dissemination, and tumor spillage with the related possibilities of locoregional and port-site recurrence are documented by several authors.1,2 Many studies have demonstrated that in case of suspected large adrenal masses, laparoscopic adrenalectomy could have outcomes similar to open procedures when surgeon strictly adheres to standard oncologic principles. Case Presentation: We report a case of a 75-year-old female patient presenting with a right-sided adrenal tumor of 75 by 70 mm, suspected for adrenocortical carcinoma, with no evidence of infiltration of periadrenal tissues or locoregional lymphadenopathy. Contrarily to the usual technique characterized by mobilization of the right triangular ligament and the retroperitoneal attachments of the right lobe, the size of the current tumor is...