The clinical course of patients with adrenal incidentaloma: is it time to reconsider the current recommendations?

ObjectiveThe current guidelines for the management of adrenal incidentaloma advise hormonal and radiological follow-up of patients for 2–5 years after the initial diagnosis. However, the vast majority of adrenal incidentaloma are non-functional benign cortical adenomas that require no treatment, so the routine application of the current strategies often results in a number of unnecessary biochemical and radiological investigations. The aim of this study was to analyse the clinical course of patients with adrenal incidentaloma and to provide a critical review of the current management strategy of the disease.Design and methodsThis was a retrospective study performed in the Croatian Referral Center for adrenal gland disorders. The study included 319 consecutive patients with adrenal incidentaloma, 174 of which were followed for at least 24 months.ResultsThe vast majority of patients were diagnosed with benign adrenal masses, whereas in about 5% of them adrenal tumor corresponded to adrenal carcinoma or metastasis. Tumor density was found to be superior to tumor size in distinguishing benign adrenal masses from malignant tumors and pheochromocytomas. During the follow-up, no patient demonstrated a clinically significant increase in tumor size. In addition, no changes, either in metanephrines and normetanephrines or in the activity of renin–aldosterone axis, were observed during the follow-up. Six patients developed subclinical Cushing's syndrome (SCS) whereas eight patients with SCS showed biochemical remission during follow-up.ConclusionThe study suggests that the risk of an adrenal mass initially diagnosed as benign and non-functional becoming malignant or hormonally active is extremely low. Therefore, the clinical management of those patients should be tailored on an individual basis in order to avoid unnecessary procedures.

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Synovial Sarcoma of the Nerve—Clinical and Pathological Features: Case Series and Systematic Review

Neurosurgery ◽

10.1093/neuros/nyz321 ◽

2019 ◽

Vol 85 (6) ◽

pp. E975-E991 ◽

Cited By ~ 2

Author(s):

Stephen Shelby Burks ◽

Ross C Puffer ◽

Iahn Cajigas ◽

David Valdivia ◽

Andrew E Rosenberg ◽

...

Keyword(s):

Systematic Review ◽

Statistical Analysis ◽

Synovial Sarcoma ◽

Tumor Size ◽

Clinical Course ◽

Case Reports ◽

Case Series ◽

Pathological Features ◽

Eligibility Criteria

Abstract BACKGROUND Synovial sarcoma of the nerve is a rare entity with several cases and case series reported in the literature. Despite an improved understanding of the biology, the clinical course is difficult to predict. OBJECTIVE To compile a series of patients with synovial sarcoma of the peripheral nerve (SSPN) and assess clinical and pathological factors and their contribution to survival and recurrence. METHODS Cases from 2 institutions collected in patients undergoing surgical intervention for SSPN. Systematic review including PubMed and Scopus databases were searched for related articles published from 1970 to December 2018. Eligibility criteria: (1) case reports or case series reporting on SSPN, (2) clinical course and/or pathological features of the tumor reported, and (3) articles published in English. RESULTS From patients treated at our institutions (13) the average follow-up period was 3.2 yr. Tumor recurrence was seen in 4 cases and death in 3. Systematic review of the literature yielded 44 additional cases with an average follow-up period of 3.6 yr. From pooled data, there were 10 recurrences and 7 deaths (20% and 14%, respectively). Adjuvant treatment used in 62.5% of cases. Immunohistochemical markers used in diagnosis varied widely; the most common are the following: Epithelial membrane antigen (EMA), cytokeratin, vimentin, cluster of differentiation (CD34), and transducin-like enhancer of split 1 (TLE1). Statistical analysis illustrated tumor size and use of chemotherapy to be negative predictors of survival. No other factors, clinically or from pathologist review, were correlated with recurrence or survival. CONCLUSION By combining cases from our institution with historical data and performing statistical analysis we show correlation between tumor size and death.

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Management of adrenal incidentalomas: European Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors

Acta Endocrinologica ◽

10.1530/eje-16-0467 ◽

2016 ◽

Vol 175 (2) ◽

pp. G1-G34 ◽

Cited By ~ 444

Author(s):

Martin Fassnacht ◽

Wiebke Arlt ◽

Irina Bancos ◽

Henning Dralle ◽

John Newell-Price ◽

...

Keyword(s):

Surgical Treatment ◽

Adrenal Mass ◽

Adrenal Incidentaloma ◽

Serum Cortisol ◽

Cushing's Syndrome ◽

Cortisol Secretion ◽

Adrenal Incidentalomas ◽

Adrenal Masses ◽

Autonomous Cortisol Secretion

By definition, an adrenal incidentaloma is an asymptomatic adrenal mass detected on imaging not performed for suspected adrenal disease. In most cases, adrenal incidentalomas are nonfunctioning adrenocortical adenomas, but may also represent conditions requiring therapeutic intervention (e.g. adrenocortical carcinoma, pheochromocytoma, hormone-producing adenoma or metastasis). The purpose of this guideline is to provide clinicians with best possible evidence-based recommendations for clinical management of patients with adrenal incidentalomas based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. We predefined four main clinical questions crucial for the management of adrenal incidentaloma patients, addressing these four with systematic literature searches: (A) How to assess risk of malignancy?; (B) How to define and manage low-level autonomous cortisol secretion, formerly called ‘subclinical’ Cushing’s syndrome?; (C) Who should have surgical treatment and how should it be performed?; (D) What follow-up is indicated if the adrenal incidentaloma is not surgically removed?Selected recommendations:(i) At the time of initial detection of an adrenal mass establishing whether the mass is benign or malignant is an important aim to avoid cumbersome and expensive follow-up imaging in those with benign disease. (ii) To exclude cortisol excess, a 1mg overnight dexamethasone suppression test should be performed (applying a cut-off value of serum cortisol ≤50nmol/L (1.8µg/dL)). (iii) For patients without clinical signs of overt Cushing’s syndrome but serum cortisol levels post 1mg dexamethasone >138nmol/L (>5µg/dL), we propose the term ‘autonomous cortisol secretion’. (iv) All patients with ‘(possible) autonomous cortisol’ secretion should be screened for hypertension and type 2 diabetes mellitus, to ensure these are appropriately treated. (v) Surgical treatment should be considered in an individualized approach in patients with ‘autonomous cortisol secretion’ who also have comorbidities that are potentially related to cortisol excess. (vi) In principle, the appropriateness of surgical intervention should be guided by the likelihood of malignancy, the presence and degree of hormone excess, age, general health and patient preference. (vii) Surgery is not usually indicated in patients with an asymptomatic, nonfunctioning unilateral adrenal mass and obvious benign features on imaging studies. We provide guidance on which surgical approach should be considered for adrenal masses with radiological findings suspicious of malignancy. Furthermore, we offer recommendations for the follow-up of patients with adrenal incidentaloma who do not undergo adrenal surgery, for those with bilateral incidentalomas, for patients with extra-adrenal malignancy and adrenal masses and for young and elderly patients with adrenal incidentalomas

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Minimally Invasive Surgery for Pediatric Adrenal Masses—Report on Four Cases

European Journal of Pediatric Surgery Reports ◽

10.1055/s-0039-1694058 ◽

2019 ◽

Vol 07 (01) ◽

pp. e75-e78 ◽

Cited By ~ 1

Author(s):

Ahmed ElHaddad ◽

Christoph Castellani ◽

Erich Sorantin ◽

Martin Benesch ◽

Eva Kampelmühler ◽

...

Keyword(s):

Minimally Invasive Surgery ◽

Minimally Invasive ◽

Invasive Surgery ◽

Malignant Tumors ◽

Adrenocortical Tumor ◽

Patient Case ◽

Simple Cyst ◽

Potentially Malignant ◽

Adrenal Masses

AbstractThe dignity of adrenal masses in children varies from benign lesions like adenoma and ganglioneuroma to malignant tumors like adrenocortical carcinoma and neuroblastoma. Any surgical approach, especially minimally invasive surgery (MIS), requires careful risk stratification based on oncological and technical criteria. Herein, we present four patients who underwent MIS for adrenal masses. Laboratory testing differentiated between simple cysts and adenoma, but could not identify a child with adrenocortical tumor preoperatively. Analysis of image-defined risk factors excluded vascular encasement in all cases. All patients underwent laparoscopic adrenalectomy without complications. Histopathology revealed simple cyst, ganglioneuroblastoma, adenoma, and potentially malignant adrenocortical tumor in one patient/case each. All specimen showed clear margins and no recurrence was noted at a mean follow-up of 18 months.

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Laparoscopic Adrenalectomy for Potentially Malignant Adrenal Tumors Greater than 5 Centimeters

The Journal of Clinical Endocrinology & Metabolism ◽

10.1210/jc.2005-2420 ◽

2006 ◽

Vol 91 (8) ◽

pp. 3080-3083 ◽

Cited By ~ 61

Author(s):

Chun-Hou Liao ◽

Shih-Chieh Chueh ◽

Ming-Kuen Lai ◽

Po-Jen Hsiao ◽

Jun Chen

Keyword(s):

Tumor Size ◽

Laparoscopic Adrenalectomy ◽

Malignant Tumors ◽

Adrenal Tumors ◽

Benign Tumors ◽

Conversion To Open Surgery ◽

Open Conversion ◽

Potentially Malignant ◽

Adrenocortical Carcinomas

Abstract Purpose: Laparoscopic adrenalectomy (LA) is controversial for large, potentially malignant tumors. We report a series of LA or hand-assisted LA for large (>5 cm) adrenal tumors. Patients and Methods: Among 210 LAs performed in 6 yr, 39 patients had potentially malignant tumors greater than 5 cm in diameter. Their perioperative and follow-up data were retrospectively analyzed. Results: All 39 patients had successful LAs without perioperative mortality, conversion to open surgery, or capsular disruption during dissection. The mean tumor size was 6.2 cm (range, 5–12 cm), operative time 207 min (115–315 min), and blood loss 75 ml (minimal–1400 ml). Complications included one intraoperative diaphragmatic perforation, three mild wound infections, and one pneumonia. Preoperatively there were 27 nonfunctioning tumors, seven pheochromocytomas, three cortisol-secreting tumors, and two virilizing tumors. Final pathology revealed eight malignant (four adrenocortical carcinomas and four metastatic carcinomas) and 31 benign tumors (14 cortical adenomas, eight pheochromocytomas, six myelolipomas, and three ganglioneuromas). Median follow-up was 39 months. Four patients (two adrenocortical carcinomas, one metastatic hepatoma, and one lymphoma) died 24, 10, 9, and 3 months after surgery, respectively. A hand-assisted device was used in 10 patients. Only the tumor size was larger and length of postoperative hospital stay longer for those in the hand-assisted group. Conclusions: LA is a reasonable option for selected large adrenal tumors when complete resection is technically feasible and there is no evidence of local invasion. Hand-assisted LA is a good alternative to open conversion if a difficult dissection is encountered intraoperatively.

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Laparoscopic Adrenalectomy for Adrenal Cancer—A Systematic Review

The American Surgeon ◽

10.1177/000313481608200517 ◽

2016 ◽

Vol 82 (5) ◽

pp. 420-426 ◽

Cited By ~ 6

Author(s):

Amanda E. Sautter ◽

Steven C. Cunningham ◽

Gopal C. Kowdley

Keyword(s):

Systematic Review ◽

Recurrence Rate ◽

Laparoscopic Adrenalectomy ◽

Malignant Tumors ◽

Cancer Recurrence ◽

Adrenal Tumors ◽

Scientific Rigor ◽

Pubmed Search ◽

Adrenal Masses

Laparoscopic adrenalectomy is increasingly employed for removal of adrenal masses. As adrenal tumors increase in size, however, their malignant potential likewise increases, raising concerns for the use of laparoscopy for removal of large adrenal malignancies. We present a systematic review of the use of laparoscopic adrenalectomy of large malignant tumors. A PubMed search was undertaken and two independent reviewers reviewed the manuscripts and a methodological index for nonrandomized studies score was determined. Manuscripts with scores greater than eight were included. The primary end points were rate of cancer recurrence, rate of conversion to open, complications, and surgical technique. Our initial search produced 412 manuscripts. After abstract review, 44 manuscripts were scored, of which 19 manuscripts were used. A total of 2183 tumors were removed, of which 517 were malignant. Average follow-up time was 38.7 months. The recurrence rate was 12.9 per cent. The rate of conversion was 3.6 per cent. The main techniques used were transabdominal and retroperitoneal. No significant differences in rate of recurrence or complications were seen when compared with open. Laparoscopic adrenalectomy may be performed for large and malignant tumors; however, most manuscripts on this subject lack significant scientific rigor and follow-up.

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Kidney tumor radiofrequency ablation progress in Lithuania

Lietuvos chirurgija ◽

10.15388/lietchirur.2013.3.1836 ◽

2013 ◽

Vol 12 (3) ◽

pp. 161-170

Author(s):

Albertas Ulys ◽

Algirdas Žalimas ◽

Rūta Merkytė ◽

Mantas Trakymas

Keyword(s):

Radiofrequency Ablation ◽

Tumor Size ◽

Renal Tumor ◽

Radical Surgery ◽

Malignant Tumors ◽

Renal Tumors ◽

The Us ◽

Vilnius University ◽

Average Tumor Size

Background / ObjectiveThis retrospective study aimed to clarify one of the minimally invasive therapies – Radiofrequency ablation (RFA) – performance, extremeness and 5-year survival in patients with small renal tumors.Patients and methods118 patients (77 men (65%), and 41 women (35%) with mean age of 68.72 (± 10.12 ) years) were treated with RFA method in Vilnius University Institute of Oncology Urology Section, and since 2003 September 17 till 2012 December 6 were performed144 renal tumor RFAs. All renal tumors RFAs were performed percutaneously in the projection of the skin, under local or general anesthesia. Procedures were performed by one or several small (up to 1 cm) incisions, and in the US control electrodeswere introduced. Since May 2011, 30 RFAs were performed with three electrodes and US control with CT navigation, just a day before the operation additionally titanium markers were put in around the kidney tumor.ResultsSince 2003 till 2007 years our patient’s follow-up method was US examination. However, in case of suspicion of tumor progression, percutaneous renal biopsy and CT were performed. From 2007 year patients were follow-up with CT. The ablationzone, contrast agent accumulation and the ablation of the edge were evaluated. Average tumor size was 2.8 (± 0.9) cm. By histology, mainly there were malignant tumors, much less benign, a minority remained histologically unconfirmed.In our study we found out that the most radical renal tumor RFAs were done in the control of US with CT navigation, when additionally around the renal tumor titanium markers were added. Also we clarified, that procedure is more radical whenperformed using three electrodes. The most common postoperative complication was paranephric hematoma.ConclusionsAfter RFA, 2-year survival rate is 90 %, 5 years – 58%. Death risk factors: tumor size, higher ASA class, non-radical surgery, metastases or other oncologic process.Key words: Radiofrequency ablation, survival, observation, fiducial markers.Inkstų navikų radiodažninės abliacijos pažanga Lietuvoje Įvadas / tikslasMūsų atlikto retrospektyviojo tyrimo tikslas – išsiaiškinti vieno iš minimaliai invazinių gydymo metodų – radiodažninės abliacijos (RDA) efektyvumą, radikalumą ir mažus inkstų navikus turinčių pacientų penkerių metų išgyvenamumą.Ligoniai ir metodai118 pacientų (77 vyrai (65 %) ir 41 moteris (35 %), amžiaus vidurkis 68,72 ± 10,12 metų) buvo gydyti RDA metodu Vilniaus universiteto Onkologijos instituto (VUOI) Urologijos skyriuje. Jiems nuo 2003 m. rugsėjo 17 d. iki 2012 m. gruodžio 6 d. buvo atliktos 144 inkstų navikų RDA. VUOI visos inkstų navikų RDA atliktos perkutaniškai, kai sukėlus vietinę ar bendrąją nejautrą, inksto projekcijos odoje atliekama viena ar kelios nedidelės (iki 1 cm) incizijos, per kurią/kurias kontroliuojant ultragarsu (UG) įkišami elektrodai ir atliekama RDA procedūra. Nuo 2011 m. gegužės 30 d. atliktos RDA su trimis elektrodais, kontroliuojamos ultragarsu su kompiuterinės tomografijos (KT) navigacija, tik dieną prieš operaciją papildomai UG kontroliuojamu būdu suleidus titaninių žymenų (TŽ) aplink inksto naviką.RezultataiMūsų tyrime nuo 2003 m. iki 2007 m. taikytas ultragarsinis ligonių stebėjimo metodas. Įtarus lokalų naviko progresavimą, buvo atliekama perkutaninė inksto biopsija ir KT. Nuo 2007 m. stebėta tik atliekant KT, kurios metu vertinta abliacijos zona, kontrastinės medžiagos (k/m) kaupimas joje ir abliacijos kraštas. Vidutinis naviko dydis buvo 2,8 (± 0,9) cm. Pagal histologiją, daugiausia buvo piktybinių navikų, daug mažiau – gerybinių, mažoji dalis liko histologiškai nepatvirtinta.Radikaliausios inkstų navikų RDA buvo atliktos kontroliuojant UG su KT navigacija ir prieš operaciją UG kontroliuojamu būdu papildomai suleidus aplink naviką titaninių žymenų. RDA yra radikalesnė, kai atliekama naudojant tris elektrodus. Duomenys parodė, kad dažniausia pooperacinė komplikacija buvo paranefrinė hematoma.IšvadosPo RDA procedūros apskaičiuota dvejų metų išgyvenamumo tikimybė – 90 %, penkerių metų – 58 %. Mūsų tyrime nustatyti mirties rizikos veiksniai – naviko dydis, aukštesnė ASA klasė, neradikali operacija, metastazės iš anamnezės, kito organo onkologinis procesas.Reikšminiai žodžiai: radiodažninė abliacija, išgyvenamumas, stebėjimas, titaniniai žymenys.

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Permanent Iodine-125 Seed Implantation for the Treatment of Nonresectable Retroperitoneal Malignant Tumors

Technology in Cancer Research & Treatment ◽

10.1177/1533033819825845 ◽

2019 ◽

Vol 18 ◽

pp. 153303381982584 ◽

Cited By ~ 3

Author(s):

Qingchun Li ◽

Yuan Tian ◽

Dongyan Yang ◽

Yun Liang ◽

Xianbin Cheng ◽

...

Keyword(s):

Pain Relief ◽

Median Survival ◽

Tumor Size ◽

Seed Treatment ◽

Malignant Tumors ◽

Survival Rates ◽

Tumor Progress ◽

Iodine 125 ◽

Tomography Scan

Purpose: This study aimed to investigate the outcomes of permanent Iodine-125 (125I) radiotherapy for patients with unresectable retroperitoneal malignant tumor. Methods: Twenty-six patients with retroperitoneal malignant tumors were implanted with 125I seeds under ultrasound guidance from June 2012 to June 2015. The patients were then followed up for 3 to 36 months after the implantation. During the follow-up, pain relief, control of tumor growth, over survival rate, and complications were evaluated. Results: Most of the patients (90%, 24/26) suffered from mild to severe pain before 125I seed treatment. After 1-month treatment, 16 patients had 100% pain relief, 4 patients had at least 50% pain relief, and 4 patients had no response, showing 83.3% of pain relief response. Results of computed tomography scan after 2-month 125I treatment indicated that 3 patients had complete remission in the tumor size, 20 patients had partial remission in tumor size, 2 patients were stable, and 1 patient had progressive disease, accounting for 88.4% response in tumor size remission. The median survival of the 26 patients was 11 months. The 1-year and 2-year overall survival rates were 46% and 27%, respectively. The median survival of the 5 patients with pancreatic cancer was 9.4 months. None of the patients had any severe complications. Conclusions: 125I implantation could effectively relieve the pain in the patients with advanced primary or metastatic retroperitoneal malignant tumors and suppress local tumor progress.

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Preoperative computed tomography angiography (CTA) of the body in vascular patients: prevalence and significance of unsuspected extravascular findings

RöFo - Fortschritte auf dem Gebiet der Röntgenstrahlen und der bildgebenden Verfahren ◽

10.1055/a-0775-2544 ◽

2019 ◽

Vol 191 (08) ◽

pp. 716-724

Author(s):

Larissa Sarah Turowski ◽

Marco Dollinger ◽

Walter A. Wohlgemuth ◽

Moritz Wildgruber ◽

Lukas Philipp Beyer ◽

...

Keyword(s):

Computed Tomography ◽

Surgical Treatment ◽

Computed Tomography Angiography ◽

Malignant Tumors ◽

Vascular Diseases ◽

The Body ◽

Radiology Reports ◽

Institutional Review ◽

Clinically Significant

Purpose Evaluation of the prevalence and significance of unsuspected extravascular findings on computed tomography angiography (CTA) of the body before endovascular or surgical treatment in vascular patients. Materials and Methods This study was approved by the local institutional review board. Radiology reports of 806 patients who underwent CTA of the body during January 2004 until December 2014 before endovascular or surgical treatment of vascular diseases were retrospectively reviewed. All unexpected extravascular abnormalities were classified as clinically non-significant (requiring no follow-up) or clinically significant (requiring further follow-up/immediate treatment). The course of patients with significant extravascular findings was retrospectively evaluated. Results Overall 806 patients were included in this study (592 men; mean age: 67 years). In 778 (96.5 %) of 806 patients 3293 incidental extravascular findings were diagnosed. There were 259 suspicious findings in 205 patients (25.4 %) that required further follow-up or immediate treatment. A previously unknown malignant tumor was diagnosed in 23 (2.9 %) patients. 10 patients (1.2 %) were diagnosed with lung cancer. Malignant tumors were detected more often in men than in women (3.5 % versus 0.9 %). Patients with an incidental tumor were significantly older than patients without a tumor (mean age: 72.3 vs. 67.5 years). Conclusion Clinically significant unexpected extravascular findings are common in vascular patients. Especially noteworthy are malignant tumors of the lung. Key points Citation Format

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Recommended evaluation of adrenal incidentalomas is costly, has high false-positive rates and confers a risk of fatal cancer that is similar to the risk of the adrenal lesion becoming malignant; time for a rethink?

Acta Endocrinologica ◽

10.1530/eje-09-0234 ◽

2009 ◽

Vol 161 (4) ◽

pp. 513-527 ◽

Cited By ~ 168

Author(s):

T J Cawood ◽

P J Hunt ◽

D O'Shea ◽

D Cole ◽

S Soule

Keyword(s):

Ct Scan ◽

False Positive ◽

Adrenal Mass ◽

Adrenal Incidentaloma ◽

Clinical Scenario ◽

True Positive ◽

Malignant Lesions ◽

Design And Methods ◽

Current Guidelines

ObjectiveTo assess the performance of current clinical recommendations for the evaluation of an adrenal incidentaloma.Design and methodsLiterature review. Electronic databases (Pubmed, Ovid and citation searches from key articles) from 1980 to 2008 were searched. Eligible studies were those deemed most applicable to the clinical scenario of a patient referred to an endocrinologist for assessment of an incidentally detected adrenal mass. Surgical series, histopathological series and oncological series were reviewed and most were excluded.ResultsThe prevalence of functional and malignant lesions presenting as adrenal incidentaloma was similar to that quoted in most reviews, other than a lower incidence of adrenal carcinoma (1.9 vs 4.7%) and metastases (0.7 vs 2.3%). The development of functionality or malignancy during follow-up was rare (<1% becoming functional and 0.2% becoming malignant). During follow-up, false-positive rates of the recommended investigations are typically 50 times greater than true positive rates. The average recommended computed tomography (CT) scan follow-up exposes each patient to 23 mSv of ionising radiation, equating to a 1 in 430 to 2170 chance of causing fatal cancer. This is similar to the chance of developing adrenal malignancy during 3-year follow-up of adrenal incidentaloma.ConclusionCurrent recommendations for evaluation of adrenal incidentaloma are likely to result in significant costs, both financial and emotional, due to high false-positive rates. The dose of radiation involved in currently recommended CT scan follow-up confers a risk of fatal cancer that is similar to the risk of the adrenal becoming malignant. This argues for a review of current guidelines.

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Outcome in patients with adrenal incidentaloma selected for surgery: an analysis of 88 cases investigated in a single clinical center

Acta Endocrinologica ◽

10.1530/eje.0.1430111 ◽

2000 ◽

pp. 111-117 ◽

Cited By ~ 41

Author(s):

JP Luton ◽

M Martinez ◽

J Coste ◽

J Bertherat

Keyword(s):

Malignant Tumors ◽

Multiple Logistic Regression Analysis ◽

Adrenal Incidentaloma ◽

High Rate ◽

Adrenal Incidentalomas ◽

Clinical Center ◽

Endocrine Status ◽

Complications Of Surgery ◽

Adrenocortical Carcinomas ◽

Design And Methods

OBJECTIVE: The study was designed to evaluate the clinical, endocrinological and radiological parameters used to investigate adrenal incidentalomas and select patients for surgery. DESIGN AND METHODS: An analysis of 88 consecutive patients with adrenal incidentaloma selected for surgery and investigated in a single clinical center was performed. RESULTS: Mean (+/-s.d.) age of the patients was 53+/-14 years. Fourteen (16%) of the adrenal incidentalomas were malignant tumors (2 adrenocortical carcinomas, 3 metastases, 4 adenocarcinomas, 4 sarcomas and 1 mesenchymoma), 10 (11%) were pheochromocytomas, 32 (36%) were non-secretory benign adrenal adenomas and the remaining were benign adrenal (n = 8; 9%) or extra-adrenal (n = 24; 27%) masses. Endocrinological investigations revealed 1 Conn adenoma, 4 tumors responsible for Cushing's syndrome or silent hypercortisolism and 1 androgen secreting tumor. Abnormalities of endocrine evaluations were observed in the 2 malignant adrenocortical carcinomas. Elevated 24-h urinary metanephrine levels were observed in the 9 pheochromocytomas tested. Complications of surgery occurred in 14% of the cases. Regardless of the endocrine status, parameters associated with malignant tumors were: older age (mean age of patients harboring malignant tumors vs patients with benign incidentalomas: 62+/-17 years vs 52+/-13 years, P = 0.005), weight loss (39% vs 7%, P = 0. 005), and mass diameter greater than 60mm (69% vs 15%, P < 0.001). By multiple logistic regression analysis malignant tumors were associated with increased age, diameter greater than 60mm and bilateral masses. CONCLUSION: This study points to a high rate of pheochromocytomas and malignant tumors in patients selected for surgery. This high rate differs from some previous reports and might be explained by the criteria used to select patients for surgery. Among these two groups of tumors, careful systematic endocrinological investigations allow the detection of altered secretion in the vast majority - if not all - malignant tumors of adrenal origin and pheochromocytomas. Only 5% of the incidentalomas below 30 mm selected for surgery in this study were malignant, in keeping with the use of this criteria as an important parameter to select patients with normal hormonal investigations for careful follow-up.

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