Treatment Of Adrenal Diseases Research Articles

Діагностично-лікувальний алгоритм комплексного хірургічного менеджменту хворих з новоутвореннями надниркових залоз

Актуальність. Проблемне поле застосування лапароскопічної адреналектомії зводиться до формулювання універсальних показань і протипоказань до операції у пацієнтів з пухлинами надниркових залоз (НЗ). Мета дослідження — розробити діагностично-лікувальний алгоритм комплексного хірургічного менеджменту хворих на патологію надниркових залоз із використанням відеоендоскопічних втручань та оцінити його клінічну ефективність. Матеріали та методи. Проаналізовано результати лікування 813 пацієнтів, яким було виконане відеоендоскопічне втручання з приводу патології НЗ. Результати. Проаналізовано результати оперативних втручань в Українському науково-практичному центрі ендокринної хірургії, трансплантації ендокринних органів і тканин МОЗ України впродовж трьох основних етапів. На першому етапі (1995–2003 рр.) проводились оперативні втручання на НЗ відкритим доступом. Другий етап (2004–2014 рр.) бере початок від дати виконання першої лапароскопічної адреналектомії в клініці центру. Третій етап (2015–2016 рр.) характеризується періодом впровадження розробок в медичну практику та їх використання. Запропонований діагностично-лікувальний алгоритм покращив результати лікування пацієнтів із захворюваннями надниркових залоз завдяки диференціальному підходу до вибору методів обстеження та визначення лікувальної тактики, вибору методу оперативного втручання. Це дозволило знизити частоту післяопераційних ускладнень до 0,5 %, післяопераційної летальності — до 0,2 %, скоротити час перебування в стаціонарі та час соціальної і трудової реабілітації хворих. Висновки. Сучасні підходи до хірургічного лікування захворювань НЗ ґрунтуються на широкому впровадженні високоефективних і малоінвазивних технологій, сприяють перегляду деяких традиційних позицій діагностичної та лікувальної тактики. Вибір операційного доступу має бути строго індивідуальним і враховувати розміри, характер новоутворення, його анатомо-топографічні взаємовідносини з оточуючими органами і тканинами, конституційні особливості пацієнта.

Diseases of the Adrenal Gland and Adrenalectomy

Evaluation and treatment of adrenal disease encompasses a broad range of disorders, including pheochromocytoma, primary hypercortisolism, primary aldosteronism, and malignancies such as adrenocortical carcinoma and metastases from other primary cancers. This pathophysiologic diversity and the technical challenges of operating on these bilateral organs with the attendant differences in left and right anatomy make adrenal surgery a complex but rewarding endeavor. Adrenal surgeons must be engaged in the physiologic aspects of the disease being treated, the anatomic details of lesion and laterality, and the technical considerations in selecting an operative approach and carrying it out successfully. Guidelines for the management of pheochromocytoma, primary hypercortisolism, and primary aldosteronism are reviewed in this chapter. Consensus is emerging that resection of adrenal metastases from other primary cancers can prolong survival in well-selected patients and that most are suitable for a laparoscopic approach. Most adrenal surgeons agree that large or locally aggressive adrenocortical carcinomas must be resected in an open fashion, though there is some controversy surrounding the operative approach in the setting of small or indeterminate lesions. Minimally invasive techniques have revolutionized adrenal surgery, and surgeons who wish to incorporate adrenal surgery into their practice must master either the laparoscopic or the retroperitoneoscopic approach. This review contains 8 figures, 2 tables, and 28 references. Key Words: adrenal cortex, adrenalectomy, adrenal incidentaloma, adrenal medulla, adrenocortical cancer, Cushing syndrome, laparoscopic adrenalectomy, pheochromocytoma, primary aldosteronism, retroperitoneoscopic adrenalectomy

Diseases of the Adrenal Gland and Adrenalectomy

Evaluation and treatment of adrenal disease encompasses a broad range of disorders, including pheochromocytoma, primary hypercortisolism, primary aldosteronism, and malignancies such as adrenocortical carcinoma and metastases from other primary cancers. This pathophysiologic diversity and the technical challenges of operating on these bilateral organs with the attendant differences in left and right anatomy make adrenal surgery a complex but rewarding endeavor. Adrenal surgeons must be engaged in the physiologic aspects of the disease being treated, the anatomic details of lesion and laterality, and the technical considerations in selecting an operative approach and carrying it out successfully. Guidelines for the management of pheochromocytoma, primary hypercortisolism, and primary aldosteronism are reviewed in this chapter. Consensus is emerging that resection of adrenal metastases from other primary cancers can prolong survival in well-selected patients and that most are suitable for a laparoscopic approach. Most adrenal surgeons agree that large or locally aggressive adrenocortical carcinomas must be resected in an open fashion, though there is some controversy surrounding the operative approach in the setting of small or indeterminate lesions. Minimally invasive techniques have revolutionized adrenal surgery, and surgeons who wish to incorporate adrenal surgery into their practice must master either the laparoscopic or the retroperitoneoscopic approach. This review contains 8 figures, 2 tables, and 28 references. Key Words: adrenal cortex, adrenalectomy, adrenal incidentaloma, adrenal medulla, adrenocortical cancer, Cushing syndrome, laparoscopic adrenalectomy, pheochromocytoma, primary aldosteronism, retroperitoneoscopic adrenalectomy

A case report of primary unilateral adrenal NK/T cell lymphoma: good clinical outcome with trimodality treatment

BackgroundPrimary natural killer (NK)/T cell lymphoma of adrenal glands is an extremely rare tumor with aggressive clinical behavior. There have only been a few cases reported worldwide and the highest reported survival was 90 days. We report the first case of primary unilateral adrenal NK/T cell lymphoma in China with good outcome.Case presentationThis is a 28-year-old man who presented with abdominal pain and was found to have a large mass on the left adrenal and the top of the renal region. The patient underwent surgical resection and the pathology revealed primary adrenal NK/T cell lymphoma. He received adjuvant sandwich therapy encompassing sequential chemotherapy, radiotherapy and chemotherapy. The patient remains clinically and symptomatically disease-free with over two years follow up.ConclusionGiven the rarity of this disease, there is limited experience with regard to its diagnosis and treatment. This case report will add to the scant literature on this tumor and will be useful for the differential diagnosis and treatment of adrenal disease.

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.

Endoscopic retroperitoneal adrenalectomy for adrenal metastases.

Objectives. To evaluate whether retroperitoneal approach for adrenalectomy is a safe and effective treatment for adrenal metastases (AM). Methods. From June 2004 to January 2014, nine consecutive patients with AM were treated with endoscopic retroperitoneal adrenalectomy (ERA). A retrospective study was conducted, and clinical data, tumor characteristics, and oncologic outcomes were acquired and analyzed. Results. Renal cancer was the primary site of malignancy in 44.4% of cases. The mean operative time was 132 ± 10.4 min. There were 5 synchronous and 4 metachronous AM. One patient required conversion to transperitoneal laparoscopic procedure. No mortality or perioperative complications were observed. The median overall survival was 11 months (range: 2–42 months). Survival rates of 50% and 25% were identified at 1 and 3 years, respectively. At the end of the study, 4 patients were alive with a mean observed follow-up of 20 months. No patients presented with local tumor relapse or port-site metastases. Conclusions. This study shows that ERA is a safe and effective procedure for resection of AM and advances the surgical treatment of adrenal disease. The use of the retroperitoneal approach for adrenal tumors less than 6 cm can provide very favorable surgical outcomes.

Sectional anatomy of the adrenal gland in the coronal plane

To provide practical anatomic data for the imaging diagnosis and surgical treatment of adrenal disease, we investigated the anatomy of the adrenal gland and its relationships to regional structures using 31 sets of serial coronal sections of upper abdomen of Chinese adult cadavers and correlated coronal magnetic resonance (MR) images of ten upper abdomens of adult healthy volunteers and coronal reconstructed multislice spiral computed tomography (MSCT) images of five patients without lesions in the adrenal gland. The adrenal glands were visualized mainly on the successive coronal sections between 18 mm anterior to the posterior margin of inferior vena cava and 24 mm posterior to the posterior margin of inferior vena cava. In general, the left adrenal gland was visualized two sections earlier than the right adrenal gland. On the plane through the anterior parts of bilateral renal hili (A18), the appearance rate of bilateral adrenal glands was 100%, and the maximal measurements of bilateral adrenal glands were visualized. The length, width, thickness of right adrenal body, thickness of medial limb and lateral limb were, respectively, 34.02 +/- 2.12 mm, 10.91 +/- 0.89 mm, 5.82 +/- 0.26 mm, 2.78 +/- 0.08 mm, 2.62 +/- 0.06 mm, whereas the measurements of left adrenal gland were 28.31 +/- 2.46 mm, 18.40 +/- 1.06 mm, 6.84 +/- 0.24 mm, 3.02 +/- 0.08 mm, 2.86 +/- 0.07 mm, respectively. The coronal plane has superior advantage in showing the bilateral adrenal glands. The shapes of adrenal glands are various, whereas the range of adrenal thickness is quite narrow. The thickness of adrenal medial and lateral limbs, especially the thickness of lateral limb are useful for the diagnosis of the bilateral adrenocortical disease.

Surrénalectomie cœlioscopique robotisée

Laparoscopy has emerged as the standard procedure for surgical treatment of benign adrenal diseases. These past 5 years, there have been concurrent improvements in the field of robotic surgery. Almost all urologic procedures initially performed laparoscopically have become performed with robotic assistance. Following a review of anatomic aspects, this paper discusses the indication, resumes the initial laboratory experience, and presents a description of the technique. Robot-assisted laparoscopic adrenalectomy has been performed in very few subjects worldwide. Advantages of robotic assistance over conventional laparoscopy are not acknowledged. Improvement in robotic technology, including addition of tactile feedback, miniaturization of end-effectors, reduced cost, and advances in remote surgery telecommunication technology are awaited. This will help in defining the place of robotics in treatment of adrenal diseases.

Use of the electrothermal bipolar vessel system (EBVS) in laparoscopic adrenalectomy: a prospective study

Since laparoscopic adrenalectomy (LA) has been adopted as the gold standard for the treatment of adrenal diseases, the development of technology for vascular control and dissection manoeuvres, amongst other things, may play a pivotal role in its further improvement. We report our experience with the electrothermal bipolar vessel sealing (EBVS) device for LA. From January 2004 to January 2006, 50 patients (pts) undergoing LA were selected and randomized for use of the EBVS (25 pts, group A) versus the UltraSonic Shears (USS) device (25 pts, group B). Age, sex, body mass index (BMI), previous surgery and associated diseases were similar between the two groups. The main surgical parameters collected for each patient (pt) concerned operative time, major and minor complications, conversion rate, blood loss, hospital stay and histology. There was no mortality in either group. The right adrenalectomy mean operative time (OpT) was 51.8 mins (range 40-90 mins) and 68.6 mins (range 50-130 mins) in group A and B, respectively (P not significant). The left adrenalectomy mean OpT was 72.2 mins (range 55-100 mins) and 94 mins (range 65-140 mins) for group A and B, respectively (P < 0.05). The mean blood loss was 83 ml (group A) and 210 ml (group B) (p < 0.05). Complications were not different for the two groups. The mean hospital stay was 2.9 and 3.1 days in group A and B, respectively (P not significant). EBVS in LA may provide a significantly short operating time and blood loss.

Alpha1 connexin 43 gap junctions are decreased in human adrenocortical tumors.

Gap junctional communication disorders have been implicated in the etiology of benign and malignant tumors. Understanding the type, distribution, and frequency of gap junctions in adrenal disorders should provide insight into the role of gap junctions in adrenal carcinogenesis as well as information that may be useful in developing improved diagnosis and treatment of adrenal diseases. Using immunocytochemical techniques, we have characterized and compared alpha1 connexins 43 gap junction protein levels in normal adrenal glands to those in benign and malignant adrenocortical human tumors. In addition, gap junction protein levels were studied in a human adrenal cancer cell line (H295). In both normal and neoplastic adrenal tissues, only alpha1 connexin 43 could be detected, whereas beta1 connexin 32 and beta2 connexin 26 were not found. In the normal adrenal gland, the zona fasciculata was demonstrated to have the highest number of gap junctions per cell (mean +/- SEM, 13.78 +/- 1.93). In contrast, in benign adrenocortical adenomas, the number of gap junctions per cell compared to that detected in normal adrenal glands was significantly reduced (mean +/- SEM, 4.6 +/- 1.17; P < or = 0.05), and the lowest number was found in malignant adrenocortical tumors (1.42 +/- 0.58; P < or = 0.05). Similarly, there were few or no alpha1 connexin 43 gap junctions in the H295 population. There was a progressive decrease in gap junction plaques in adrenocortical cancer cell populations compared to those in normal cell populations. Therefore, analysis of gap junction protein may be helpful for the differential diagnosis of benign and malignant adrenal tumors. The induction of gap junctions in malignant cells may provide a novel therapeutic strategy for adrenal cancer.

Surgical Treatment of Adrenal Diseases at Nara Medical University and Affiliated Hospitals

The effect of advanced diagnostic imaging on the surgical treatment of adrenal diseases was examined in 86 cases of adrenal disease surgically treated at the Department of Urology, Nara Medical University, and affiliated hospitals from August, 1962, to July, 1991. The number of cases included in the present study was 16 for the period before the introduction of CT (from 1962 to 1978), and 70, including 13 cases of adrenal incidental tumor, after the introduction of CT in 1979. There were no malignant tumors histopathologically, among the 13 cases of incidental tumor. Accurate localization of functioning adrenal disease was possible at a rate of 100% with angiography, including selective venous blood sampling, 98.6% with CT and 84.5% with ultrasonography. The rate was 100% with magnetic resonance imaging which was carried out on 19 cases (20 adrenal glands). Signs of malignancy were observed in the removed tissue of three cases from the pheochromocytoma group. As the diagnostic imaging technique has improved, the use of a flank approach has increased in the surgery for adrenal disease.

Clinical Uses of Adrenal Steroids.

This extremely current and inclusive collection of 17 papers belongs to a group of clinical publications sponsored by the University of California Medical Extension Series. The book, written by 22 specialists mainly from California but also some from other medical centers, is divided into 2 sections. The first is concerned with the clinical use of steroids in the treatment of adrenal diseases, of diseases of connective tissue (the collagen diseases) and specific fields of medicine such as allergy, dermatology, lung disease, gastrointestinal disease, renal disease, and neoplastic and hematologic diseases. The second section deals with basic knowledge concerning the biochemistry of steroids, their structuralfunctional relationships, the effects of steroids on water and electrolyte metabolism and renal function, and lastly the effects of steroids on the metabolism of carbohydrate, protein, and fat. These chapters, by S. Roberts, J. M. Koplowitz and C. R. Kleeman, and J. Brown, respectively, are notably clear with ample classical and current references. Also of note is the introductory chapter by P. K. Bondy who presents an extremely objec¬ tive and philosophical approach to the use of steroids in clinical medicine. The book may serve as a guide for both the internist and for the specialist who deals with the use of steroids in certain disease states. The book is particularly useful to the physician with less experience in the use of steroids and to the physician de¬ liberating in a given patient whether steroid therapy should be instituted. George F. Cahill, Jr., M.D.

Clinical Uses of Adrenal Steroids

This extremely current and inclusive collection of 17 papers belongs to a group of clinical publications sponsored by the University of California Medical Extension Series. The book, written by 22 specialists mainly from California but also some from other medical centers, is divided into 2 sections. The first is concerned with the clinical use of steroids in the treatment of adrenal diseases, of diseases of connective tissue (the "collagen" diseases) and specific fields of medicine such as allergy, dermatology, lung disease, gastrointestinal disease, renal disease, and neoplastic and hematologic diseases. The second section deals with basic knowledge concerning the biochemistry of steroids, their structuralfunctional relationships, the effects of steroids on water and electrolyte metabolism and renal function, and lastly the effects of steroids on the metabolism of carbohydrate, protein, and fat. These chapters, by S. Roberts, J. M. Koplowitz and C. R. Kleeman, and J. Brown, respectively, are notably clear