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PubMed1991

[Diagnosis of adrenal diseases focusing on morphological and endocrinological viewpoints].

The recent advances in the diagnosis of adrenal diseases owe much to the rapid progress in radiological and endocrinological areas. The former is ascribed to the progress of medical electronics. The latter has been realized by the development, improvement and spread of the measurement of a very small amount of hormones or hormone-like substances in blood, urine or tissues, supported by the improvement of measurement instruments as well as the immunoassay or chemical assay techniques. This paper reviews approaches to diagnosis of adrenal diseases causing hypertension and asymptomatic, incidentally discovered adrenal tumors. Incidentally discovered adrenal tumors have increased owing to the spread of medical electronic instruments such as abdominal ultrasonography (US), computed tomography (CT) and magnetic resonance imaging (MRI). Discrimination of malignancy is an important clinical concern. More than 90% of the tumors reported in the Japanese were larger than 3 cm in diameter. The diagnosis of primary aldosteronism has been made by the measurement of plasma renin and aldosterone, CT and 131I-cholesterol scintigraphy. However the differential diagnosis of adrenal adenoma from bilateral adrenal hyperplasia has remained as a problem. There were a few patients in whom adrenal adenomas appeared after 2-3 years' follow-up period. In Cushing's syndrome, tumors are found with ease by US, CT and MRI. The diagnosis of pheochromocytoma is made mainly by urinary catecholamines and metabolites including metanephrine, normetanephrine and VMA. US, CT and MRI are very useful. Diagnosis and discovery of metastasis will be more reliably made when 131I-MIBG comes to the clinical stage.(ABSTRACT TRUNCATED AT 250 WORDS)

Adrenal Gland Diseases↗
PubMed1978

[Microdetermination of corticosteroids in adrenocortical zones in various adrenal diseases (author's transl)].

Since the relationship between steroidogenic activity and morphological differentiation is not necessarily clear in the human adrenal cortex, aldosterone (Al), cortisol (F) and corticosterone (b) from the adrenal tissues cut into four small pieces (capsule and glomerulosa, outer fascicular, inner fascicular, and reticular zones) on a cryostat immediately after their removal at surgery were estimated by radioimmunoassay in 15 patients with adrenal diseases (8 primary aldosteronism, 1 idiopathic aldosteronism, 4 Cushing's syndrome and 2 pheochromocytoma) and 8 control subjects with other diseases. A larger amount of Al was contained in the outer fascicular zone than in other zones in control subjects. Al showed a high value of 0.16 approximately 7.40 ng/mg tissue in adenomas of primary aldosteronism and a low value of 0 approximately 0.25 ng/mg tissue in adenomas of Cushing's syndrome. A high value of Al was detected in idiopathic aldosteronism but not in the remaining adrenal of primary aldosteronism. In Cushing's syndrome, F showed a high value of 2.58 approximately 12.3 ng/mg tissue in adenoma and a relatively low level of 0.77 ng/mg tissue in carcinoma. A larger amount of F and B was found in the inner fascicular zone than in other zones in the control subjects. These results indicate that the corticosteroid content in each adrenal zone correlates with the morphological findings.

Adenoma↗
PubMed1990

[Adrenal apoplexy--endogenous, exogenous and therapeutic multiplicity].

From the aspect of morbidity, adrenal apoplexy is primarily a disease of newborns or infants, frequently with subclinical rather than frank manifestations. The development is governed by the susceptibility fetal processes of adrenal transformation to disturbances and injury. Exogenous causes such as birth trauma and bacterial inflammation, are seen in some cases, as are sympathogenous neoplasms. When it is diagnosed some uncertainty about benign or malignant development of the disorder persists in the background. With sonography now available as a diagnostic tool, in the majority of the cases conservative monitoring for a tendency to spontaneous resorption is enough. This approach, however, also involves the risk of identifying a protracted circulatory shock or the growth of an adrenal tumor too late. The surgeon also faces the problem of possible misinterpretation of hematoma impacted into the fascia of the capsule of Gerota as a nephroblastoma with consequent erroneous treatment. The relative rareness of the disorder means surgeons have little personal experience with it, which compounds the difficulties. In comparison with the situation in children, treatment of the adult form of the disorder appears almost simple.

Adrenal Gland Diseases↗
PubMed1994

[Contribution of nuclear medicine to the diagnosis of silent adrenal masses].

The role of adrenal scintigraphy in the noninvasive characterization of silent adrenal masses was investigated in 40 patients. The mass had been detected by US or CT performed in the evaluation of non-malignant extra-adrenal diseases (25 cases) or during staging or follow-up of a malignant extra-adrenal neoplasm (15 cases). In all cases radio-cholesterol scintigraphy (74 MBq i.v. of 131I-6 beta-iodomethylnorcholesterol in 19 cases; 11 MBq i.v. of 75Se-6 beta-selenomethylnorcholesterol in 21 cases) was performed; in 7 cases also 131I-MIBG scan (18.5-37 MBq i.v.) was carried out. When compared with CT data, radiocholesterol scintigraphy (standard or after suppression with dexamethasone) showed: concordant uptake (increased uptake of radiocholesterol on the side of the adrenal mass) in 24/26 patients with adrenal cortical adenoma; discordant uptake (absent or decreased uptake on the side of the adrenal mass) in 12 patients: 5 with adrenal metastases and 7 with non-adenomatous benign space-occupying lesions (2 ganglioneuromas, 1 post-traumatic hemorrhagic lesion, 3 adrenal cysts, 1 myelolipoma); indeterminate uptake (symmetric bilateral uptake) in 4 patients: 2 with a small adenoma, 1 with adrenal metastasis and 1 with a "false incidentaloma" (hepatic regenerative nodule). The results confirm the utility of radiocholesterol scintigraphy in demonstrating the benignity of adrenal lesions (particularly in identifying adrenocortical adenomas) and assess its place among the procedures used to characterize silent adrenal masses. The possible use of MIBG scintigraphy is also discussed.

Adrenal Gland Diseases↗
PubMed2001

Laparoscopic adrenalectomy: the optimal surgical approach.

BACKGROUND AND PURPOSE: Laparoscopic adrenalectomy has emerged as the treatment of choice for most adrenal surgical disorders. We describe our experience with 176 laparoscopic operations. PATIENTS AND METHODS: The patients were treated for hyperaldosteronism (N = 62), pheochromocytoma (N = 43), "incidentaloma" (N = 21), Cushing's syndrome (N = 20), suspected adrenal metastasis (N = 16), Cushing's disease (N = 8), adrenal hemorrhage (N = 3), or virilizing tumor (N = 1). In 154 of the 176 laparoscopic operations, a lateral transabdominal approach (15 bilateral, 76 left, and 63 right) was used. In the remaining 22, a posterior laparoscopic approach (3 bilateral, 10 left, and 9 right) was used. RESULTS: The average total operating time for unilateral laparoscopic adrenalectomy was 2.8 hours, and for bilateral adrenalectomy, it was 5.2 hours. The mean tumor size was 4.6 cm (range 1-15 cm). There was no significant difference in operating time according to the tumor size. The average length of hospitalization was 1.7 days (range 1-9 days). The perioperative complication rate was 5.1%. There were no conversions to an open procedure. The operating time, length of hospitalization, and perioperative complication rate were stable over the period. Although we used the posterior laparoscopic approach only for smaller tumors (<6 cm), we found no differences in patient outcome between the lateral and posterior laparoscopic approaches. CONCLUSION: For almost all adrenal surgical disorders, an initial laparoscopic approach is optimal. It is safe and is associated with the best patient outcome.

Adolescent↗
PubMed1996

Abnormal thyroid and adrenocortical function test results in intensive care patients.

A prospective, cohort study of 75 consecutive patients requiring management in the medical intensive care unit (MICU) of the Singapore General Hospital was carried out over a five-month period to determine thyroid and adrenocortical profiles and evaluate their use in predicting patient outcome. Up to 88% of patients had at least one abnormal thyroid function and 77% had abnormal adrenocortical function test results. There were significantly lower triiodothyronine, thyroxine and free thyroxine, but not thyrotropin levels, and higher cortisol levels in non-survivors compared to survivors (all P < 0.01). Of the endocrine parameters, triiodothyronine and cortisol concentrations were independent predictors of outcome. The overall predictive accuracy of combining these two variables on admission into the MICU was 74%. The APACHE II (acute physiology and chronic health evaluation II) score alone predicted outcome with 71% accuracy, and in combination with triiodothyronine and cortisol levels improved accuracy to 84%. The use of dopamine alone predicted outcome with 74% accuracy, and in combination with triiodothyronine and cortisol levels, improved accuracy to 84%. Measurements of total triiodothyronine and cortisol concentrations on admission to the MICU, and consideration of the use of dopamine improve on the APACHE II score in outcome prediction.

APACHE↗
PubMed1988

[Localization of primary hyperaldosteronism].

After diagnosis of primary aldosteronism on the basis of biochemical evidence, the detection of the tumour is of crucial importance in the management of the disease. We reviewed the efficacy of CT-Scan, Iodo-Cholesterol Scintigraphy, digitalized phlebography, adrenal vein sampling for steroid measurements (AVS), and Nuclear Magnetic Resonance (NMR) in 160 hypertensive patients with primary aldosteronism. Diagnosis of Conn's adenoma (n = 96) or Adrenal Hyperplasia (n = 40) was confirmed by surgery or at least two concordant tumour localization tests. Scintigraphy gave a correct diagnosis in 53% of the 51 exams, CT-Scan in 82% of the 85 exams, and phlebography in 79% of 61 exams. Plasma Aldosterone/Cortisol ratio was 5 times higher on the side of adenoma in 55% of the 47 cases but this ratio was also present in 23% of 22 patients with adrenal hyperplasia. Each procedure exhibited few false positive and false negative cases. NMR performed in 15 patients with Conn's adenoma identified all the cases. But tumours displayed a signal close to the liver signal and identical to the normal adrenal. These results and the risk of invasive procedure (failure of catheterization of the right adrenal vein (n = 6) and adrenal haematoma (n = 2) lead us to propose a schema of exploration of patients with primary aldosteronism. The CT-Scan could be performed at the first step once the biological diagnosis confirmed. Phlebography and AVS will be performed only if tumour was less than 1 cm at the CT-Scan despite important biological abnormalities. This schema requires to be validated by a prospective evaluation.

Adenoma↗
PubMed1999

Laparoscopic adrenalectomy for nonmalignant disease: improved safety, morbidity, and cost-effectiveness.

BACKGROUND: Laparoscopic adrenalectomy has rapidly gained widespread acceptance for treatment of benign adrenal neoplasms. A number of authors have compared various anatomic approaches to laparoscopic adrenalectomy, comparing length of inpatient stay, transfusion requirements, and perioperative complications. Separate studies have found inpatient stay reduced 40-60% with the use of laparoscopic adrenalectomy vs. an open procedure. METHODS: There have been no studies designed specifically to examine and compare perioperative morbidity, length of stay, and patient charges in patients undergoing laparoscopic adrenalectomy. This report examines the Johns Hopkins Hospital experience with laparoscopic adrenalectomy in 22 patients, comparing length of stay, perioperative morbidity, and patient charges. These data are compared with those seen in 17 patients undergoing open adrenalectomy within our institution and 70 patients at all other nonfederal hospitals in the state of Maryland. RESULTS: Outcomes after laparoscopic versus open adrenalectomy were compared. Resumption of diet (1.6 vs. 6.1 days), independent activity (1.6 vs. 7.9 days), inpatient length of stay (1.7 vs. 7.8 days), and total hospital patient charges ($8,698 vs. $12,610) were all significantly reduced in patients undergoing laparoscopic adrenalectomy at our institution. Similar findings were obtained when our data were compared against adrenalectomy performed at other hospitals within the state of Maryland. Length of stay (1.7 vs. 8.9 days) and total hospital patient charges ($8,698 vs. $13,867) were both significantly reduced compared to state-wide data in patients treated with laparoscopic adrenalectomy. CONCLUSIONS: Although a technically challenging procedure, laparoscopic adrenalectomy provides clear advantages over open procedures for the vast majority of adrenal neoplasms. Our data support the conclusion that laparoscopic adrenalectomy should be considered for all patients with benign adrenal neoplasms.

Adolescent↗
PubMed2001

18F-FDG PET in characterizing adrenal lesions detected on CT or MRI.

UNLABELLED: The purpose of this study was to evaluate the ability of (18)F-FDG PET to characterize adrenal lesions in patients with proven or suspected cancers. METHODS: A retrospective analysis was performed on 50 adrenal lesions in 41 patients, whose PET scans were done to evaluate the primary or metastatic disease. CT had shown 50 adrenal lesions in 41 patients and MRI had revealed 13 lesions in 10 patients. There were 34 patients with proven malignancy (28 lung cancer, 3 thyroid cancer, 2 colorectal cancer, and 1 lymphoma) and 7 with lung nodules. Of the 50 lesions, 18 were eventually determined to be malignant either by histopathology (n = 7) or by follow-up (n = 11). The remaining 32 lesions were proven or assumed to be benign by histopathology (n = 4) or clinical follow-up (n = 28). Unlike previously published reports, PET was interpreted as positive if the uptake was equal to or greater than that of the liver. RESULTS: No malignant lesion yielded a negative result on PET. Most lesions (13/18) showed significantly higher FDG uptake than that of the liver. In the remaining 5 lesions (2 metastases from neuroendocrine tumor, 2 early metastases, and 1 necrotic metastasis), FDG uptake was equal to or slightly higher than that of the liver. Of the 32 benign lesions, there were 2 lesions with uptake equal to or slightly higher than that of the liver, 3 with uptake less than the liver but more than the background, and 27 with uptake of the background. MRI identified 3 of the 13 lesions as false-positives but FDG PET correctly identified all 3 as benign. The other 10 adrenal lesions accurately diagnosed by MRI were also characterized by PET. FDG PET for characterization of adrenal lesions showed a sensitivity of 100%, a specificity of 94%, and an accuracy of 96%. CONCLUSION: FDG PET showed excellent diagnostic performance in differentiating adrenal lesions detected on CT or MRI. Because FDG PET has the additional advantage of evaluating the primary lesions as well as metastases, it could be cost-effective and the modality of choice for the characterization of adrenal lesions, especially in patients with malignancy.

Adrenal Gland Diseases↗
PubMed1997

Anterior, posterior, or laparoscopic approach for the management of adrenal diseases?

BACKGROUND: At the advent of laparoscopic adrenalectomy it seemed timely to us to assess the advantages and the overall results of the different techniques that are currently used in an approach to adrenalectomy. PATIENTS AND METHODS: Between 1984 and 1995, 165 patients underwent adrenalectomy. Eighty-six patients (37 men and 49 women with a mean age of 46.4 years) underwent adrenalectomy via the anterior approach, 61 patients (18 men and 43 women with a mean age of 43.8 years) underwent posterior extraperitoneal adrenalectomy, and 18 patients (8 men and 10 women with a mean age of 48.7 years) underwent anterior laparoscopic adrenalectomy. For statistical analysis of the different comparisons between the groups we used the t test for independent samples, the Wilcoxon test, chi-square, and one way analysis of variance. RESULTS: There was no operative mortality. The morbidity was 13.9% in the anterior approach, 9.8% in the posterior approach, and 0% in the laparoscopic approach. The mean operating time for unilateral adrenalectomy was 155.3 min (range 75 to 315) for the anterior approach, 108.6 min (range 60 to 195) for the posterior approach and 116.1 min (range 75 to 180) for the laparoscopic approach. For bilateral adrenalectomy the mean operating time was 165 min for the anterior and 178 min for the posterior approach. The average diameter of tumors resected anteriorly was 8.07 cm (range 2.5 to 20), posteriorly was 5.25 cm (range 0.5 to 14), and laparoscopically was 4.03 cm (range 2 to 6.5). The mean length of postoperative hospitalization for patients undergoing unilateral adrenalectomy was 8 days (range 2 to 25) for the anterior approach, 4.5 days (range 1 to 11) for the posterior approach, and 2.2 days (range 1 to 5) for the laparoscopic approach. Patient controlled analgesia lasted 3.4 days for those operated anteriorly, 2.3 days for those operated posteriorly, and 1.08 days for those that underwent laparoscopic adrenalectomy. CONCLUSIONS: The laparoscopic approach to the adrenal promises the safest and least painful operation with shorter in-hospital stay and the best cosmetic and long-term results. The posterior approach is the fastest of all and a better overall operation than the anterior approach that should only be reserved for removing very large adrenal tumors and when concomitant intra-abdominal procedures, that can't be handled laparoscopically, are anticipated.

Adolescent↗
PubMed2004

Outcome of laparoscopic adrenalectomy for pheochromocytomas vs aldosteronomas.

HYPOTHESIS: Laparoscopic adrenalectomy (LA) is most commonly performed for pheochromocytomas (PHEs) and aldosteronomas (ALDs). We hypothesize that LA for these differing tumor types is associated with different operative courses and outcomes. DESIGN: Retrospective study of a 10-year experience with LA. SETTING: University teaching hospital. PATIENTS: Laparoscopic adrenalectomy was performed on 149 patients. During data analysis, the initial 35 LAs performed for various adrenal lesions were excluded to account for the learning curve. Twenty-six of 30 PHEs and 34 of 45 ALDs were included. MAIN OUTCOME MEASURES: Analysis of variance was used to compare operative time, tumor size, estimated blood loss, and postoperative length of hospital stay between the PHE and ALD groups and subsets of these groups. chi(2) Analysis was used to compare tumor location, transfusion requirements, conversion to open procedures, and incidence of major complications. RESULTS: Right-sided lesions occurred in 19 of 26 PHEs, and left-sided lesions occurred in 28 of 34 ALDs (P <.001). Mean +/- SD tumor size of PHEs (4.9 +/- 1.8 cm) was larger than that of ALDs (2.7 +/- 1.7 cm) (P <.001). Mean +/- SD operative time for PHEs vs ALDs was 191 +/- 49 vs 162 +/- 48 minutes (P =.02). Mean +/- SD estimated blood loss was greater for PHEs (276 +/- 298 mL) than for ALDs (196 +/- 324 mL) (P =.33). Subset analysis revealed that the mean +/- SD size of right-sided PHEs (5.3 +/- 1.8 cm) was significantly larger than that of right-sided ALDs (3.0 +/- 1.5 cm) (P=.001). Mean +/- SD operative time for right-sided PHEs (198 +/- 44 minutes) was longer than that for right-sided ALDs (145 +/- 37 minutes) (P=.005). Six PHE patients required blood transfusions vs 2 ALD patients (P =.05). Two LAs, 1 PHE and ALD, were converted to open procedures. Mean +/- SD length of hospital stay was longer for PHE patients vs ALD patients (4 +/- 4 vs 2 +/- 3 days; P =.08). Six PHE patients had complications vs 3 ALD patients (P =.13). CONCLUSIONS: For PHEs, LA was associated with the removal of more right-sided lesions, larger tumors, longer operative times, and more complications. Trends toward greater estimated blood losses and longer hospital stays were observed for PHEs vs ALDs. Despite the advanced skills of an experienced surgeon, LA for PHEs is associated with a more complex course than for ALDs. Surgeons should begin performing LA for ALD early in their experience to avoid the potential pitfalls associated with PHEs.

Adrenal Gland Diseases↗
PubMed2000

Vascular adrenal pseudocyst: cytologic and immunohistochemical study.

Adrenal vascular cysts are rare lesions that might be considered in the differential diagnosis of adrenal tumors. Their origin is not clear. We report the clinicopathological findings of a large adrenal hemorrhagic pseudocyst (AHP) in a 73-yr-old man who complained of abdominal pain. An abdominal CT showed a 9 cm tumor in the left adrenal. A fine-needle aspiration biopsy (FNAB) was hemorrhagic and inconclusive. The tumor was excised and touch imprints were taken showing groups of spindled and fusiform cells with elongated nuclei, without atypia. Histologically, the tumor was well delimited by a fibrous capsule and contained numerous cystic spaces lined by endothelial cells and filled with erythrocytes, fibrin thrombus, and necrotic debris. Immunohistochemical study showed strong positivity for factor VIII-RA, CD31, and CD34. Also, the remaining adrenal showed a prominent frame of thin and medium caliber vessels, supporting a vascular origin for this entity. This case illustrates the difficulty in making a diagnosis by FNA and to keep in mind AHP when hematic aspirates are obtained from an adrenal tumor mass.

Adrenal Gland Diseases↗
PubMedDate not supplied

Laparoscopic surgery for adrenal lesions.

Laparoscopy has become an important tool in the urologist's armamentarium. The optimal utilization of this technology is still in evolution; however, it offers assistance in diagnosis and treatment for a variety of conditions. As experience with laparoscopy increases, more procedures that have traditionally been done with an open surgical approach will be adapted to use with the laparoscope. In this article, we review current applications of laparoscopic adrenalectomy.

Adrenal Gland Diseases↗