Periadrenal Fat Research Articles

7469 A Case of Severe Transient Hypercortisolism In a Patient With Bacterial Meningitis

Abstract Disclosure: R. Harxhi: None. D.V. Mihailescu: None. Background: Increased cortisol levels are known to occur in states of significant stress caused by acute illness. This may be attributed to stress leading to a rise in the corticotrophin releasing hormone thereby increasing adrenocorticotrophic hormone levels. This may consequently result in severe transient hypercortisolism and bilateral adrenal structural changes.Clinical case:A 55-year-old female with a past medical history of HTN and pre-diabetes presented to the hospital with a headache and altered mental status starting the day prior to admission. On arrival, she was found to be hypertensive, confused and was diagnosed with acute bacterial meningitis caused by streptococcus pneumoniae. Initial labs were notable for a potassium level of 2.5 mEq/L (normal 3.5-5 mEq/L). Work-up of persistent hypokalemia revealed a cortisol of 54.83 ug/dL (normal 6.7-22.6 ug/dL), ACTH 166 pg/mL (normal 9-50 pg/mL), aldosterone < 1 ng/dL (normal 3-16 ng/dL), and renin 0.57 (normal 0.25-5.82). CT of the abdomen showed bilateral periadrenal fat stranding, larger on the left with no adrenal nodules. On physical exam, patient did not exhibit any cushingoid features. Significantly elevated AM cortisol levels persisted despite treatment with high dose dexamethasone as part of the meningitis regimen (20 mg) resulting in unsuppressed AM cortisol of 9.22 ug/dL. An MRI of the brain showed a partially empty sella rendering a pituitary adenoma unlikely. Patient’s clinical status improved rapidly, and hypokalemia resolved. A low dose dexamethasone suppression test performed 9 days post admission produced an appropriately suppressed cortisol (1.0 ug/dL) and ACTH (14 pg/mL) levels, thus confirming a functional response to acute illness. Conclusion: This is a rare case of severe transient hypercortisolism with periadrenal congestion (“fat stranding”) resulting in hypokalemia (likely due inappropriate activation of mineralocorticoid receptors) in the setting of acute illness. There have been a very limited number of similar cases reported in literature, particularly with respect to CNS infections. It is important to recognize the response to acute stress could produce significant elevation of cortisol levels leading to the activation of mineralocorticoid receptors, therefore mimicking primary hyperaldosteronism. Presentation: 6/1/2024

A computed tomography-based comprehensive standardized adrenal tumor scoring model for predicting the perioperative outcomes of retroperitoneal laparoscopic adrenal surgery.

Many imaging scoring models have been developed for tumor surgery to provide critical guidance for the selection of surgical methods. However, little research has been aimed at developing scoring models for adrenal tumors and retroperitoneal laparoscopic adrenal surgery (RLAS), which has become the primary technique for treating adrenal tumors. The study set out to establish a computed tomography (CT)-based adrenal tumor scoring model for predicting perioperative outcomes in patients with adrenal tumors who have undergone RLAS. The retrospective analysis included 306 patients with adrenal tumors diagnosed by preoperative unenhanced or enhanced CT from January 2014 to August 2018 in the First Affiliated Hospital of Fujian Medical University. CT images were used to quantify the tumor location and size; the relationships of the tumors with the surrounding organs and tissues, the large abdominal blood vessels, and the upper poles of the kidneys and renal hila; the adhesion of periadrenal fat (PF); and the tumor CT enhancement value. We conducted multivariate ordinal logistic regression analysis to screen variables and performed principal component analysis to construct a novel scoring model for RLAS. The perioperative outcomes of RLAS were evaluated according to postoperative length of stay, operative time (OT), intraoperative blood loss (IBL), and postoperative complications. The final scoring model included tumor size; the relationships of the tumors with the surrounding organs and tissues, the large abdominal blood vessels, and the upper poles of the kidneys and renal hila; the tumor CT enhancement value; the adhesion of the PF; and the functional status of adrenal tumors. The total score had positive correlations with the OT (rs=0.431), IBL (rs=0.446), and postoperative length (rs=0.180) (all P values <0.001). Compared to any single metric, the total score provided better prediction of OT and IBL. The grading system for RLAS based on the scoring model also performed well in predicting the complexity and difficulty of RLAS. The coincidence rate for these factors was good (all P values <0.001). The developed model is feasible and repeatable in the prediction of the perioperative outcomes, complexity, and difficulty of RLAS.

A radiomics based approach using adrenal gland and periadrenal fat CT images to allocate COVID-19 health care resources fairly

BackgroundThe value of radiomics features from the adrenal gland and periadrenal fat CT images for predicting disease progression in patients with COVID-19 has not been studied extensively. We assess the value of radiomics features from the adrenal gland and periadrenal fat CT images in predicting COVID-19 disease exacerbation.MethodsA total of 1,245 patients (685 moderate and 560 severe patients) were enrolled in a retrospective study. We proposed a 3D V-net to segment adrenal glands in onset CT images automatically, and periadrenal fat was obtained using inflation operation around the adrenal gland. Next, we built a clinical model (CM), three radiomics models (adrenal gland model [AM], periadrenal fat model [PM], and fusion of adrenal gland and periadrenal fat model [FM]), and radiomics nomogram (RN) after radiomics features extracted.ResultsThe auto-segmentation framework yielded a dice value 0.79 in the training set. CM, AM, PM, FM, and RN obtained AUCs of 0.717, 0.716, 0.736, 0.760, and 0.833 in the validation set. FM and RN had better predictive efficacy than CM (P < 0.0001) in the training set. RN showed that there was no significant difference in the validation set (mean absolute error [MAE] = 0.04) and test set (MAE = 0.075) between predictive and actual results. Decision curve analysis showed that if the threshold probability was between 0.4 and 0.8 in the validation set or between 0.3 and 0.7 in the test set, it could gain more net benefits using RN than FM and CM.ConclusionsRadiomics features extracted from the adrenal gland and periadrenal fat CT images are related to disease exacerbation in patients with COVID-19.

Clinical predictors and significance of adherent periadrenal fat in laparoscopic adrenalectomy

BackgroundAdrenalectomy requires the anatomic preparation of the adrenal gland in the fat-rich retroperitoneal space. In the literature, it was shown that the retroperitoneal fat area affects surgical outcomes in laparoscopic adrenalectomy (LA). Besides the quantity of retroperitoneal fat, its qualitative properties play hypothetically a significant role in the safety profile and perioperative parameters of LA. In this study, we aimed to evaluate the factors associated with adherent periadrenal fat.MethodsThe prospectively obtained demographic, preoperative, intraoperative, and postoperative data of 44 patients who underwent laparoscopic adrenalectomy in our clinic were analyzed retrospectively. The patients were divided into two groups as adherent periadrenal fat (APAF) and non-APAF group. Periadrenal fat tissue was defined as adherent or non-adherent by the attending surgeon according to the difficulty in dissection of the adrenal gland from the surrounding fat tissue during the operation.ResultsThe rate of female gender and presence of diabetes mellitus (DM) was higher in the APAF group (respectively, p = 0.038 and p = 0.001). A ROC curve analysis showed that the cut-off point was − 97 HU for APAF. On multivariable analysis using a stepwise regression model, we identified the presence of DM (OR = 5.073; 95% Cl = 2.192–12.387; p = 0.006) and ARFD > -97 HU (OR = 3.727; 95% Cl = 1.898–11.454; p = 0.008) as an independent predictor of APAF.ConclusionAPAF seems to affect the perioperative outcomes of LA in terms of operation duration but not perioperative complications.

PSUN375 What Blindness and Paraganglioma Have in Common? A Rare Case of Paraganglioma Syndrome

Abstract Background Pheochromocytomas and paragangliomas (PPGLs) are rare neuroendocrine tumors with an annual incidence in the U.S. of 500-1600 cases per year. Approximately 30-35% of PPGLs harbor germline mutations, while 35-40% are due to somatic mutations. Recent studies have identified the association between somatic mutations of the hypoxia-inducible factor 2 alpha (HIF2A) gene and a new syndrome of PPGLs associated with congenital polycythemia. Patients present with recurrent PPGLs, congenital malformation of intracranial veins, malformation of macula and retina, and type I Chiari malformations. Case A 44-year-old man with history of in-utero stroke, congenital blindness, polycythemia and spinal stenosis had an incidental para-aortic lesion found during workup of back pain. He experienced episodic palpitations associated with diaphoresis, headache and uncontrolled hypertension for the past eight year. There was no family history of neuroendocrine tumors. Dedicated abdominal computer tomography with contrast showed a right adrenal enhancing lesion measuring 1.4×1.2 cm and a conglomerate of heterogenous enhancing periaortic lesions measuring up to 5 cm in the mid-abdomen. Biochemical work up revealed plasma free normetanephrine of 27.5 nmol/L (0.00-0.89) and plasma free metanephrines of 0.49 nmol/L (0.00-0.49). Gallium 68 DOTATATE scan showed multiple avid retroperitoneal lesions measuring up to 4.4 cm and an avid right adrenal nodule. He underwent right adrenalectomy and para-aortic lesion resection with perio-operative alpha blockade. Pathology confirmed synchronous pheochromocytoma (1.5 cm, Ki-67&amp;lt; 1%, with capsular and periadrenal fat invasion) and paraganglioma (9.3 cm, Ki-67 &amp;lt; 1%, with lymphovascular invasion and one out of nine lymph nodes positive for metastatic disease). Post-operatively, his metanephrines normalized and a six-months positron emission tomography scan showed no evidence of disease. Genetic testing has been delayed. Discussion This case illustrates a rare syndrome of PPGLs, congenital blindness, and polycythemia, likely due to somatic mutations of HIF2a. HIF is an alpha/beta heterodimer. HIF2a becomes a transcription factor after dimerization with HIF2b. Any mutations that stabilize HIF protein leads to transcription of hypoxia inducible genes resulting in angiogenesis, polycythemia, and tumorigenesis. In our patient, we suspect the stroke in-utero may have been related to abnormal intracranial angiogenesis and/or polycythemia. Recognition of this syndrome and lifelong surveillance is imperative due to risk of recurrence of PPGL. Targeted therapies such as a HIF2a inhibitor have been proposed and trials are ongoing. Our patient remains disease free on radiographic and biochemical surveillance. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

The Adhesive Perinephric Fat Score is Correlated with Outcomes of Retroperitoneal Laparoscopic Adrenalectomy for Benign Diseases

BackgroundRetroperitoneal laparoscopic adrenalectomy (RLA) possessing unique superiority with minimal abdominal interference is complicated by the status of periadrenal fat, including its quantity and texture. We hypothesized that an adherent perinephric fat predictor, the Mayo Adhesive Probability score (Mayo score), is associated with the perioperative outcomes of RLA.MethodsThis retrospective study included consecutive patients who underwent RLA for the diagnosis of benign adrenal tumors at our institution between 2017 and 2020. Medical records were reviewed to evaluate the association between Mayo scores obtained from preoperative computed tomography imaging and surgical outcomes as well as complications. Factors independently related to perioperative results were analyzed using multivariable regression models.ResultsIn total, 186 RLA were included. According to their Mayo scores, the patients were divided as follows: 0 (n = 51, 27.4%), 1 (n = 34, 18.3%), 2 (n = 45, 24.2%), 3 (n = 29, 15.6%), 4 (n = 16, 8.6%) and 5 (n = 11, 5.9%). Longer operative time (92.0 ± 25.0 vs. 114.7 ± 30.6 vs. 137.4 ± 27.1 min, P < 0.001), higher estimated blood loss (42.2 ± 28.1 vs. 70.5 ± 44.9 vs. 132.6 ± 63.4 mL, P < 0.001) and greater decline of hemoglobin (0.7 ± 0.4 vs. 1.0 ± 0.4 vs. 1.3 ± 0.6 g/dL, P < 0.001) were significantly associated with elevated Mayo score risks. No difference in complication rates was found. The score was identified as a unique, independent risk factor for perioperative outcomes on multivariable analysis.ConclusionsThe Mayo score is a vital outcome predictor of RLA. It may be utilized in the preoperative planning for patients undergoing RLA.

Autonomous cortisol secretion is associated with worse arterial stiffness and vascular fibrosis in primary aldosteronism: a cross-sectional study with follow-up data.

The presence of autonomous cortisol secretion (ACS) in patients with primary aldosteronism (PA) is common and potentially associated with poor outcomes. The aim of this study was to investigate the association between ACS and vascular remodeling in PA patients. We prospectively enrolled 436 PA patients from October 2006 to November 2019. ACS (defined as a cortisol level >1.8 μg/dL after a 1 mg dexamethasone suppression test) was detected in 23% of the PA patients. Propensity score matching (PSM) with age, sex, systolic and diastolic blood pressure was performed. The brachial-ankle pulse wave velocity (baPWV) was examined at baseline and 1 year after targeted treatment. Small arteries of periadrenal fat in 46 patients were stained with Picro Sirus red to quantify the severity of vascular fibrosis. After PSM, the PA patients with ACS had a significantly higher prevalence of diabetes mellitus, higher plasma aldosterone concentration and higher aldosterone-to-renin ratio. The baseline mean baPWV was also significantly higher in the PA patients with ACS. After multivariable regression analysis, the presence of ACS was a significant predictor of worse baseline mean baPWV (β: 235.745, 95% CI: 59.602-411.888, P = 0.010). In addition, the PA patients with ACS had worse vascular fibrosis (fibrosis area: 25.6 ± 8.4%) compared to those without ACS (fibrosis area: 19.8 ± 7.7%, P = 0.020). After 1 year of PA treatment, baPWV significantly improved in both groups. The presence of ACS in PA patients is associated with worse arterial stiffness and vascular remodeling.

New predictive factors for prolonged operation time of laparoscopic posterior retroperitoneal adrenalectomy; retrospective cohort study

BackgroundLaparoscopic adrenalectomy is a standard surgical procedure for benign adrenal diseases. Laparoscopic posterior retroperitoneal adrenalectomy (LPRA) has many benefits. However, it is associated with factors such as prolong operation time. The aim of the study was to determine the predictive factors associated with prolonged operation time in LPRA. Materials and methodsThis study retrospectively analyzed data from 284 patients who underwent LPRA between 2014 and 2019 at Asan Medical Center. Then, we analyzed the predictive factors prolonging operation time using multivariate logistic regression analysis and classified the differences according to the learning curve using cumulative sum analysis. ResultsIn multivariate logistic regression analysis, the following were determined as factors associated with prolonged operation time: male sex (OR, 2.540; 95% CI, 1.225–5.266), pheochromocytoma (OR, 3.669; 95% CI, 1.548–8.694), right site (OR, 2.499; 95% CI, 1.086–5.748), surgeon A (OR, 3.293; 95% CI, 1.522–7.122), depth of descended adrenal tumor location to kidney (OR, 3.793; 95% CI, 1.660–8.667), large periadrenal fat volume (OR, 2.366; 95% CI, 1.120–4.996), and posterior adiposity index (PAI) (OR, 2.171; 95% CI, 1.090–4.324) (all p < 0.05). However, in the period after the learning curve, periadrenal fat volume was not a significant predictor of surgery time prolongation. ConclusionThis study demonstrates that depth of descended adrenal tumor location to kidney is a new and important independent predictive factor for prolonged operation time in LPRA. In addition, periadrenal fat volume is a predictor of surgery time prolongation for beginner surgeons before the learning curve.

Recruitment and remodeling of peridroplet mitochondria in human adipose tissue

Beige adipocyte mitochondria contribute to thermogenesis by uncoupling and by ATP-consuming futile cycles. Since uncoupling may inhibit ATP synthesis, it is expected that expenditure through ATP synthesis is segregated to a disparate population of mitochondria. Recent studies in mouse brown adipocytes identified peridroplet mitochondria (PDM) as having greater ATP synthesis and pyruvate oxidation capacities, while cytoplasmic mitochondria have increased fatty acid oxidation and uncoupling capacities. However, the occurrence of PDM in humans and the processes that result in their expansion have not been elucidated. Here, we describe a novel high-throughput assay to quantify PDM that is successfully applied to white adipose tissue from mice and humans. Using this approach, we found that PDM content varies between white and brown fat in both species. We used adipose tissue from pheochromocytoma (Pheo) patients as a model of white adipose tissue browning, which is characterized by an increase in the capacity for energy expenditure. In contrast with control subjects, PDM content was robustly increased in the periadrenal fat of Pheo patients. Remarkably, bioenergetic changes associated with browning were primarily localized to PDM compared to cytoplasmic mitochondria (CM). PDM isolated from periadrenal fat of Pheo patients had increased ATP-linked respiration, Complex IV content and activity, and maximal respiratory capacity. We found similar changes in a mouse model of re-browning where PDM content in whitened brown adipose tissue was increased upon re-browning induced by decreased housing temperature. Taken together, this study demonstrates the existence of PDM as a separate functional entity in humans and that browning in both mice and humans is associated with a robust expansion of peri-droplet mitochondria characterized by increased ATP synthesis linked respiration.

A Radiomics Based Approach Using Adrenal Gland and Periadrenal Fat CT Images to Fairly Allocate COVID-19 Health Care Resources

Background: COVID-19 disease severity is associated with endocrine system. We hypothesis radiomics features from the adrenal gland and periadrenal fat CT images can assess possibilities of disease exacerbation.Methods: A total of 1,245 patients (685 moderate and 560 severe patients) were enrolled in a retrospective study. We proposed 3D V-Net to segment adrenal glands in onset CT images automatically, and periadrenal fat was obtained using inflation operation around the adrenal gland. Next, we built a clinical model (CM), three radiomics models (adrenal gland model [AM], periadrenal fat model [PM], and fusion of adrenal gland and periadrenal fat model [FM]), and radiomics nomogram (RN) after radiomics features extracted.Findings: The auto-segmentation framework yielded a dice value of 0.79 in the training set. CM, AM, PM, FM, and RN obtained AUCs of 0.717, 0.716, 0.736, 0.760, and 0.833, respectively in the validation set. FM and RN had better predictive efficacy than CM (P Interpretation: Radiomics features extracted from adrenal gland and periadrenal fat CT images are related to disease exacerbation in patients with COVID-19.Funding Information: The study was supported by the Non-profit Central Research Institute Fund of Chinese Academy of Medical Sciences (2019PT320003）; The Science and Technology Foundation of Guizhou Province (QKHPTRC[2019]5803); The Guiyang Science and Technology Project (ZKXM[2020]4); Beijing Medical and Health Foundation (YWJKJJHKYJJ-B20261CS) and Chongqing Science and Health Joint Medical Research Project (2021MSXM052).Declaration of Interests: The authors have declared that no conflict of interest exists.Ethics Approval Statement: This multicenter study was approved by the ethics committees of all participating hospitals (2020,NO.01). Because of its retrospective nature, the need to obtain informed consent in advance was waived. The study was performed according to the principles of the declaration of Helsinki.

Periadrenal Volume is a Better Predictor of Prolonged Operative Time in Laparoscopic Retroperitoneal Adrenalectomy than BMI.

Retroperitoneal laparoscopic adrenalectomy is gaining traction as a minimally invasive technique. One of the purported relative contraindications is BMI given the smaller working space. We hypothesize that other anthropometric measurements may be better predictors of operative time. An IRB-approved, single-institution, retrospective study of 83 patients who underwent laparoscopic retroperitoneal adrenalectomy evaluated the association of anthropometric measurements taken from cross-sectional imaging and the primary outcome of operative time. Descriptive statistics were performed with Wilcoxon rank-sum test for continuous variables (median; IQR) and Chi-square (n; %) for categorical variables. A linear random effects model was used to model operative time. The majority of the patients were white (40; 48.2%) women (46; 55.4%) with a median age of 54 with interquartile range (IQR) of 43-63 and a median BMI of 27.8 (IQR 21.2-38.6). On univariable analysis, factors that led to longer operative time included right-sided operation (p = 0.04), male gender (p < 0.01), clinical diagnosis (p < 0.01), waist area (p < 0.01), waist/hip ratio (p < 0.01), periadrenal volume (p < 0.01), posterior adiposity index (PAI) (p < 0.01) and BMI (p < 0.01). Only side, order of operation, and periadrenal fat volume (p < 0.01, p = 0.02 and p < 0.01, respectively) remained independent predictors of increased operative time on multivariable analysis. This study demonstrates that anthropometric measurements, specifically periadrenal fat volume, and side of operation, are better predictors for increased operative time in laparoscopic retroperitoneal adrenalectomies than BMI. This information can help facilitate appropriate patient selection for this operative approach.

Management of blunt adrenal gland injury in a community-based hospital

IntroductionInjury of the adrenal gland in blunt trauma is rare. The routine usage of the whole body computed tomography (CT) scan helps in early diagnosis. We aimed to study the incidence, mechanism of injury, management, and outcome of adrenal injury in blunt trauma patients treated in a community-based hospital. MethodsCT scan of the abdomen of all blunt trauma patients who were admitted to our institution between October 2010 and March 2018 were retrospectively reviewed. The files of all the patients with CT scan-detected adrenal injuries were retrieved. Studied variables included demography, mechanism of injury, associated injuries, GCS, ISS, Intensive Care Unit admission, hospital stay, and outcome. Results4991 blunt trauma patients were admitted to the hospital. CT scan of the abdomen was performed for 2359 (47%) patients. Blunt adrenal injuries were diagnosed in eleven male patients (0.22%). The main mechanism of injury was motor vehicle collisions in eight (72.7%) patients. Nine (81.8%) patients had right adrenal gland injury. The mean (range) ISS was 22 (6–50). All patients had intra-adrenal hematoma and periadrenal fat stranding. None of our patients had acute adrenal insufficiency. One patient died (overall mortality 9.1%). ConclusionsThe incidence of blunt adrenal injury, although rare, is similar in a community-based hospital to those reported from trauma I centers. It is associated with severe and multiple organ injuries. Blunt adrenal injuries are usually self-limiting.

Isolation, Fixation, and Immunofluorescence Imaging of Mouse Adrenal Glands

Immunofluorescence is a well-established technique for detection of antigens in tissues with the employment of fluorochrome-conjugated antibodies and has a broad spectrum of applications. Detection of antigens allows for characterization and identification of multiple cell types. Located above the kidneys and encapsulated by a layer of mesenchymal cells, the adrenal gland is an endocrine organ composed by two different tissues with different embryological origins, the mesonephric intermediate mesoderm-derived outer cortex and the neural crest-derived inner medulla. The adrenal cortex secretes steroids (i.e., mineralocorticoids, glucocorticoids, sex hormones), whereas the adrenal medulla produces catecholamines (i.e., adrenaline, noradrenaline). While conducting adrenal research, it is important to be able to distinguish unique cells with different functions. Here we provide a protocol developed in our laboratory that describes a series of sequential steps required for obtaining immunofluorescence staining to characterize the cell types of the adrenal gland. We focus first on the dissection of the mouse adrenal glands, the microscopic removal of periadrenal fat followed by the fixation, processing and paraffin embedding of the tissue. We then describe sectioning of the tissue blocks with a rotary microtome. Lastly, we detail a protocol for immunofluorescent staining of adrenal glands that we have developed to minimize both non-specific antibody binding and autofluorescence in order to achieve an optimal signal.

Posterior retroperitoneoscopic approach to the adrenal arteries.

Differently from transperitoneal adrenalectomy, with the posterior retroperitoneoscopic approach adrenal arteries are dissected first [1, 2]. Knowledge of their position is pivotal as they are covered by peri-adrenal fat [3, 4]. Four posterior retroperitoneoscopic adrenalectomies were selected, in which adrenal arteries are dissected to show their path and how they can be localized among peri-adrenal fat. A video is presented herein, which focuses on surgical anatomy of adrenal arteries when approached during a posterior retroperitoneoscopic adrenalectomy. Details about relative positions between adrenal arteries and adjacent structures are considered and shown during their dissection. The posterior retroperitoneoscopic approach offers a direct view of adrenal arteries and allows for their exposure and safe division in the early steps of adrenalectomy.

Augmented Adipocyte Browning and Mitochondrial Function in Periadrenal Fat but not Subcutaneous Fat in Pheochromocytoma Patients

Background and aimsThis study aimed to characterize browning in periadrenal (pADR) and subcutaneous adipose tissue (SAT) depots in humans with pheochromocytomaMethodspADR and abdominal SAT samples were collected from patients undergoing adrenalectomy for aldosterone, cortisol‐secreting and non‐functioning neoplasms for the study control group (n=23) and patients with benign unilateral pheochromocytoma (n=15). Plasma catecholamine levels were measured by HPLC. The presence of unilocular or multilocular adipocytes was assessed by H&amp;E staining and brightfield microscopy. UCP1 abundance was measured at the gene expression level by qPCR and protein by immunohistochemistry and western blotting. Mitochondria were isolated from the tissue samples and respiration analysed on an XF24 Seahorse Extracellular Flux Analyzer. Whole transcriptome analysis was carried out in pADR fat by Illumina microarray.Results60% (9/15) of the pheo group showed browning of periadrenal fat recorded by the presence of multilocular adipocytes. Interestingly, those patients with browning in pADR fat had the highest levels of plasma catecholamines. Control pADR fat samples showed no multilocular adipocytes. No patients in either control or pheo groups showed browning of SAT. This was corroborated with UCP1 protein found in multilocular pADR fat in pheos but not in SAT. Pheo patients with multilocular pADR fat had increased mitochondrial respiration in pADR compared to controls or pheos with unilocular adipocytes. Specifically, we detected higher complex 1 to 4 respiration of the electron transport chain, while uncoupled respiration was higher. No difference was observed in respiration from SAT mitochondria. No increase was seen in plasma ANP, BNP or FGF21 in pheo patients compared to controls. Finally, microarray analysis in pADR revealed a distinct gene expression signature in pheo patients with multilocular adipocytes, characterized by enhanced expression of genes required for fatty acid oxidation and mitochondrial respiration.ConclusionsBrowning of pADR occurs in some patients with pheochromocytoma but is not observed in SAT. This browning may be driven by elevated plasma nor‐epinephrine in these subjects. Our data demonstrates for the first time that the multilocular pADR adipose tissue observed in pheo patients has increased mitochondrial respiration, suggesting potentially significant effects on energy metabolism in vivo.Support or Funding InformationFunded by the Leducq Foundation and the Cardiometabolic Research Foundation, Los Angeles

Computed Tomography Appearance of Surgically Resected Adrenal Hematomas.

Adrenal hemorrhages arise as a result of a number of conditions and may exhibit a variety of appearances on computed tomography (CT). On occasion, patients will undergo adrenalectomy for treatment of a presumptive adrenal neoplasm that on surgical pathology is identified as an adrenal hemorrhage. We evaluated the CT appearance of surgically resected adrenal masses from our institution over a period of 15 years that ultimately proved to be adrenal hematomas. A surgical pathology archive was queried for all cases of adrenal hemorrhage. Only cases with a corresponding diagnostic CT were included. Cases were excluded if an underlying adrenal mass was present. For the remaining cases, the CT appearances were evaluated by 2 radiologists quantitatively and qualitatively. Our search yielded 18 cases of adrenal hemorrhage, of which 5 cases had corresponding CT and no underlying secondary process within the adrenal. All of the adrenal hematomas in this series demonstrated an ovoid morphology and were well defined, with an average maximum diameter of 8.9 cm and highly variable attenuation on noncontrast CT (average attenuation range, 13.1-44.0 Hounsfield units [HU]). Four of the 5 lesions had degrees of peripheral enhancement that was either thin and somewhat uniform or heterogeneous and irregular. None of the lesions demonstrated invasion of the periadrenal fat or adjacent organs. Adrenal hematomas with a mass-like configuration offer a potential diagnostic dilemma for radiologists and surgeons. Although it is rare that an adrenal hemorrhage is surgically resected, awareness of the potential appearances of these lesions is important to spare patients from unnecessarily aggressive surgery.

Invasive phaeochromocytoma presenting as a right atrial mass

A 56-year-old man with a history of hypertension and panic attacks for 30 years presented with increasing palpitations, especially after strenuous activity, that had already lasted for 1 year. Initial assessment with an echocardiogram showed a right atrial mass. Subsequent imaging revealed a right adrenal mass extending into the renal vein, inferior vena cava, and right atrium (fi gure). We identifi ed no evidence of distant metastatic disease by 18F-fl uorodeoxyglucose PET-CT imaging. Through biochemical analysis, we confi rmed the diagnosis of phaeochromocytoma, with plasma-free normetanephrine at a concentration of 13 936 pg/mL (normal range 0–145 pg/mL) and metanephrines at a concentration of 129 pg/mL (normal range is 0–62 pg/mL). After treatment with α-blockers, a right atriotomy and venotomy of the inferior vena cava with en-bloc resection of the primary tumour, including intracaval and intraatrial segments, was done. Pathology analysis confi rmed phaeo chromocytoma (TNM stage pT3 pNX pMX) extending into the inferior vena cava and right atrium, and invading the adrenal capsule and periadrenal fat with margins free of tumour. A Pheochromocytoma of the Adrenal Gland Scaled Score of 11 suggested malignancy. Early surgical cure was confi rmed by normal biochemical testing 8 months after surgery. In view of low clinical suspicion of multiple endocrine neoplasia type 2 or neurofi bromatosis type 1, we initiated genetic testing sequentially for Von Hippel–Lindau disease, the result of which was negative. Subsequently, mutational analysis of the succinate dehydrogenase gene was planned, but the patient was lost to follow-up. This case shows a haematogenously invasive phaeo chromocytoma without evidence of distant metastases to confi rm malignancy. Although phaeochromocytomas with cavo–atrial extension are rarely described in the medical literature, the disorder is commonly seen in patients with renal cell carcinoma. About 10% of phaeochromocytomas are malignant, and malignancy is most common in patients with SDHB mutations. Surgery is seldom curative. Vascular invasion, mitotic activity, and cellular atypia might suggest aggressive tumour behaviour, but cannot defi nitively predict metastatic potential. Metastases are typically used to diagnose malignancy, but no molecular or histological markers exist to confi rm a malignant phaeochromocytoma. After 30 years of symptoms related to the phaeo chromocytoma, this patient had no metastases, despite surgical pathology fi ndings suggestive of malignancy. Early surgical remission is promising, although the patient will need lifelong monitoring for recurrence.

Are traumatic bilateral adrenal injuries associated with higher morbidity and mortality?-A prospective observational study.

BackgroundTraumatic bilateral adrenal injuries are uncommon. Adrenal injuries are overall associated with worse outcome than non-adrenal injuries. However, direct comparative evidence between unilateral and bilateral adrenal injuries is unavailable in literature. This study aims to investigate clinical significance of bilateral adrenal hematomas in terms of injury severity, morbidity and mortality.MethodsAll blunt trauma abdomen patients with adrenal gland involvement on initial CECT scans of abdomen presenting to our Level 1 trauma centre over 21 months were prospectively included and followed-up. Patients were divided into unilateral and bilateral adrenal hematoma groups. For all patients, mechanism of injury, initial pulse, blood pressure, respiratory rate, Glasgow Coma Scale (GCS) scores, Injury Severity Score (ISS), New Injury Severity Score (NISS), length of ICU stay (LOI), length of hospital stay (LOS), total blood products (TBP) received were recorded. Final outcome was noted as complete recovery; discharge with poor prognosis and death. Quantitative parameters between both groups were compared using appropriate statistical tests and P < 0.05 was considered significant.ResultsForty seven patients were detected to have adrenal hematomas, 34 with unilateral (30 right and 4 left) and 13 with bilateral involvement. An oval mass replacing the gland was the most common appearance of injury (35/60) and periadrenal fat stranding was most common associated finding (47/60). Patients with bilateral adrenal hematoma had significantly lower GCS (13 vs 15, P < 0.01), ISS (38 vs 22, P < 0.01), NISS (47 vs 21, P < 0.01), LOI as proportion of LOS (91.7 % vs 10.5 %, P = 0.01) and TBP received (10 vs 4 units, P < 0.05). Outcome in bilateral group was comparatively worse with higher proportion of deaths or discharge with poor prognosis (P = 0.000).ConclusionsPatients with bilateral adrenal injury are associated with higher injury severity, morbidity and mortality compared to unilateral adrenal injury.

Right robotic adrenalectomy for a 8 cm pheochromocytoma (with video)

Please cite this article in press as: Sessa L, et al. Right robotic adrenalectomy for a 8 cm pheochromocytoma (with video). Journal of Visceral Surgery (2015), http://dx.doi.org/10.1016/j.jviscsurg.2015.06.010 Pheochromocytoma; Robotic surgery; Minimally invasive surgery; Robotics CT scan showed a 10 cm right adrenal tumor compatible with a pheochromocytoma. MIBG scintigraphy confirmed a right adrenal tumor single uptake. Routine biomolecular evaluation (SDHx and VHL genes) was negative for a familial disease. A totally robotic lateral transperitoneal right adrenalectomy was performed. The patient was placed in left lateral strict decubitus and flexed at the waist. An ‘‘open’’ right subcostal access was used to introduce a 12 mm optical trocar. Under laparoscopic vision (0◦ scope), 4 other trocars were introduced: two 8 mm right subcostal trocars, one 12 mm and one 10 mm trocars for the first-assistant’s left and right (liver retractor) hand, respectively. The robotic cart (da Vinci® Si Surgical System, Intuitive Surgical) was placed above the patient’s right shoulder and was docked. Intra-abdominal exploration confirmed the presence of a large retroperitoneal mass that completely modified the right suprarenal region. The right triangular ligament was divided and the liver was medially retracted. The right aspect of the vena cava was not initially accessible because of the large adrenal mass volume. Consequently, the tumor was first dissected, en bloc with the periadrenal fat, from the upper pole of the kidney and from lateral attachments to obtain an adequate mobilization of the adrenal mass allowing its rotation to better approach the right lateral and posterior aspects of the vena cava. Then, dissection was carried out progressively upward along the inferior vena cava on the medial margin of the tumor. Four large adrenal veins were consecutively dissected, clipped using nonabsorbable self-locking clips (Hem-o-lok®, Weck-Telefex Europe Ltd.), and divided. The adrenal mass was completely dissected and mobilized from its posterior aspect (iliopsoas muscle). Overall operative time was 90 minutes. No post-operative complication was observed hospitalization duration was 3 days. Pathology confirmed an adrenal pheochromocytoma, 8 cm in diameter with a PASS score 1 with R0 resection without capsular effraction.

27. Adrenal oncocytic pheochromocytoma with probable malignant potential: a unique case report

Oncocytic pheochromocytomas are exceedingly rare tumours. To date, there are 3 reported cases in the literature. We present a case of a 68-year-old man with moderate hypertension and an incidental adrenal mass on radiological investigations. The patient had normal levels of 24-hour urine cortisol, metanephrines and non-metanephrines. The tumour was subsequently excised. Macroscopic examination revealed a light brown, 45×35×35mm, 36g tumour of the adrenal gland. Histologically, the tumour cells showed oncocytic appearance with high-grade nuclear abnormalities and foci of extension into the peri-adrenal fat. Immunohistochemical studies revealed that the tumour was positive for chromogranin, S-100 and p53 and negative for inhibin, HMB-45 and EMA. The malignant potential of pheochromocytoma is known to be difficult to predict. Two scoring systems were used; PASS (phaeochromocytoma of adrenal scaled score) by Thompson and a Japanese scoring system by Kimura and colleagues. Both scoring systems predicted the tumour had a malignant potential. However, no recurrence was detected after 5 years of follow-up. In summary, this is the first reported case of oncocytic pheochromocytoma with probable malignant potential.