Management Of Adrenal Disease Research Articles

Evaluation and management of adrenal neoplasms: endocrinologist and endocrine surgeon perspectives

The evaluation and management of adrenal disease is a complex endeavor that relies on an expert knowledge of human physiology and anatomy. Careful and proper patient assessment mandates a balanced approach which marries the disciplines of endocrinology, surgery, and radiology. Any of these three specialties may be on the front line in performing the initial workup when an adrenal neoplasm is discovered. With an ever-increasing volume of cross-sectional imaging, be it CT, MRI, or PET, large numbers of adrenal incidentalomas are being discovered. A close collaboration amongst specialties should strive to streamline the initial evaluation and minimize unnecessary testing and treatment.

Retroperitoneal vs. transperitoneal laparoscopic adrenalectomy: a meta-analysis of the literature

Minimally invasive surgery is becoming the mainstay of surgical treatment. Two laparoscopic techniques have been developed in the management of adrenal disease—retroperitoneal and transperitoneal laparoscopic adrenalectomy. A literature search has been carried out in PubMed, MEDLINE, EMBASE and Google Scholar academic search engines, using the MeSH terms “Adrenalectomy”, “Randomised Controlled Trials”, “Retroperitoneal”, “Transperitoneal”, “Laparoscopy”. All randomized controlled trials published until January 2016 comparing retroperitoneal and transperitoneal laparoscopic adrenalectomy were identified. Data were collected on operative performance, operative time and post-operative management. Each outcome was calculated with 95% confidence intervals (CI). Three blinded prospective randomised controlled studies were used. When compared to transperitoneal laparoscopic adrenalectomy, retroperitoneal laparoscopic adrenalectomy has comparable blood loss (χ2 = 11.24; P = 0.0008; CI −2.67, 6.73; I2 = 91%), operative time (χ2 = 5.77; P = 0.06; CI −0.41, 3.19; I2 = 65%) and post-operative pain (χ2 = 1.31; P = 0.25; CI −0.5, 1.33; I2 = 24%). Retroperitoneal laparoscopic adrenalectomy is associated with a significantly shorter time to oral intake (χ2 = 7.56; P = 0.006; CI 1.93, 5.13; I2 = 87%), ambulation (χ2 = 0.09; P = 0.77; 2.64, 8.58; I2 = 0%) and hospital stay (χ2 = 2.23; P = 0.14; CI 0.44, 1.68; I2 = 55%). Retroperitoneal laparoscopic adrenalectomy is significantly better than transperitoneal laparoscopic adrenalectomy with regards to time to oral intake, ambulation and hospital stay. There is no significant difference between the two with regards to blood loss, operative time and post-operative pain.

Adrenal lesions encountered in current medical practice − a review of their radiological imaging

Modern radiological technology has transformed the way that adrenal lesions are currently investigated. The contemporary radiologist has been catapulted to the forefront in the management of adrenal disease. With the increasing use of cross-sectional imaging, adrenal lesions are being serendipitously discovered in radiological studies undertaken for non-adrenal-related conditions – the so-called adrenal ‘incidentaloma’. This review discusses the imaging modalities available for characterising these lesions, highlighting current concepts and controversies in differentiating benign from malignant pathology. The article also provides a brief overview of the spectrum of adrenal pathology commonly encountered in the adult population.

Adrenal lesions encountered in current medical practice − a review of their radiological imaging

Modern radiological technology has transformed the way that adrenal lesions are currently investigated. The contemporary radiologist has been catapulted to the forefront in the management of adrenal disease. With the increasing use of cross-sectional imaging, adrenal lesions are being serendipitously discovered in radiological studies undertaken for non-adrenal-related conditions – the so-called adrenal ‘incidentaloma’. This review discusses the imaging modalities available for characterising these lesions, highlighting current concepts and controversies in differentiating benign from malignant pathology. The article also provides a brief overview of the spectrum of adrenal pathology commonly encountered in the adult population.

Recent Trends in Surgical Management of Adrenal Diseases

Recent Trends in Surgical Management of Adrenal Diseases

The pathology of pituitary, thyroid and adrenal gland tumours

Endocrine tumours are relatively rare in clinical practice. Most are sporadic, but some occur in familial settings such as the multiple endocrine neoplasia syndromes type I (MEN I) and type II (MEN II, Figure 1). They are usually non-functional, but may secrete hormones that give rise to clinical syndromes. An example is Cushing's syndrome, caused by secretion of adrenocorticotrophic hormone (ACTH) from a pituitary adenoma or cortisol secretion from an adrenocortical tumour. Recent technical advances have enabled pathologists to provide specific diagnostic and prognostic information. For example, immunohistochemical staining with antibodies to specific hormones and other proteins can define the tumour as endocrine in nature and provide a hormone profile. The level of cell proliferation can be calculated by identifying cells positive for nuclear proteins that are expressed only when the cell is in cycle (e.g. Ki-67). This article should be read in conjunction with ‘Investigation and management of adrenal disease’, page 305.

Investigation and management of adrenal disease

Disorders of the adrenal glands are rare and complex, with many potential pitfalls in their investigation and treatment. An understanding of embryology, anatomy and physiology is crucial. Surgical treatment may be required for syndromes of hormonal excess or suspicion of neoplasia. Two important principles of endocrine surgery are: • Ensure that a suspected biochemical disorder is confirmed or excluded before attempting localization of abnormal adrenal morphology. • The investigation and treatment of adrenal disorders should be agreed in a multidisciplinary setting consisting of biochemists, endocrinologists, endocrine surgeons and radiologists.

Imaging for adrenal tumours

Modern medical imaging has transformed the diagnosis and management of adrenal disease. The various types of adrenal tumours bear different aspects of problems in diagnostic imaging. The investigation used must be determined and monitored individually, as directed by the clinical and biochemical findings. CT plays a central role in the localization of the functioning adrenal tumours. It is regarded as the imaging modality of choice because it combines safety with a high rate of detection. It is highly sensitive in the localization of the large adrenal tumours that account for Cushing's syndrome and phaeochromocytomas, as well as the small tumours that account for primary hyperaldosteronism. It is, however, not reliable for the detection of adrenal hyperplasia, and does not yield functional imaging information. For small tumours not detectable by CT, and for ectopic tumours, complementary investigations with appropriate application of venous sampling, radionuclide scintigraphy and occasionally arteriography, will be very useful. CT-guided percutaneous biopsy is employed for the incidentalomas in oncologic patients. MRI appears to hold a great potential for the diagnosis of adrenal disorders, but this modality is awaiting wider availability of instrumentation and clearer documentation of techniques.

Adrenal surgery: Trends during the seventies

Surgical experience with adrenal disease from 1970 to 1979 was reviewed in 315 patients. The pathologic conditions that were encountered were hypercortisolism (74 patients), hyperaldosteronism (46 patients), adrenocortical carcinoma (35 patients), pheochromocytoma (77 patients), and nonfunctioning adenoma (47 patients). In addition, 5 patients with metastatic lesions, 14 with cysts, and 4 with myelolipoma were surgically treated. The accuracy of localizing adrenal lesions increased from about 50 percent to almost 100 percent during the decade studied. The increase was due mainly to the introduction of computerized tomography, the most important advance in the management of adrenal disease. The present study shows that adrenal surgery can be performed with low morbidity and mortality. Operative deaths were confined to patients with malignant disease or increased secretion of cortisol or catecholamines. Only patients with adrenocortical carcinoma (2 year survival probability, 34 percent) or hypercortisolism due to cortical hyperplasia (5 year survival probability, 76 percent) had significantly decreased survival.