Predictors of complication after adrenalectomy

ABSTRACT Purpose: To investigate risk factors for complications in patients undergoing adrenalectomy. Materials and Methods: A retrospective search of our institutional database was performed of patients who underwent adrenalectomy, between 2014 and 2018. Clinical parameters and adrenal disorder characteristics were assessed and correlated to intra and post-operative course. Complications were analyzed within 30-days after surgery. A logistic regression was performed in order to identify independent predictors of morbidity in patients after adrenalectomy. Results: The files of 154 patients were reviewed. Median age and Body Mass Index (BMI) were 52-years and 27.8kg/m2, respectively. Mean tumor size was 4.9±4cm. Median surgery duration and estimated blood loss were 140min and 50mL, respectively. There were six conversions to open surgery. Minor and major post-operative complications occurred in 17.5% and 8.4% of the patients. Intra-operative complications occurred in 26.6% of the patients. Four patients died. Mean hospitalization duration was 4-days (Interquartile Range: 3-8). Patients age (p=0.004), comorbidities (p=0.003) and pathological diagnosis (p=0.003) were independent predictors of post-operative complications. Tumor size (p<0.001) and BMI (p=0.009) were independent predictors of intra-operative complications. Pathological diagnosis (p<0.001) and Charlson score (p=0.013) were independent predictors of death. Conclusion: Diligent care is needed with older patients, with multiple comorbidities and harboring unfavorable adrenal disorders (adrenocortical carcinoma and pheocromocytoma), who have greater risk of post-operative complications. Patients with elevated BMI and larger tumors have higher risk of intra, but not of post-operative complications.

A functioning adrenal adenoma and pheochromocytoma in the same adrenal gland: two discrete adrenal incidentalomas

No abstract available.

Hipoglucemia inducida por carcinoma adrenal / Adrenal carcinoma induced hypoglycemia

El carcinoma suprarrenal es una neoplasia maligna infrecuente y de mal pronóstico. La presentación clínica más común es originada por la producción hormonal excesiva, mientras que el desarrollo de hipoglucemia sintomática es excepcional. Presentamos el caso de una mujer de 37 años que ingresó al hospital por síntomas de hipoglucemias graves, hipertensión arterial, hipopotasemia y amenorrea secundaria. En el laboratorio se halló hipoglucemia con insulina inhibida y niveles de andrógenos en rango tumoral. La tomografía computarizada (TC) de abdomen y pelvis mostró voluminosa formación heterogénea de aspecto sólido sin plano de clivaje con respecto al parénquima hepático e intenso realce con contraste. Luego de la extirpación de la masa retroperitoneal, evolucionó con valores de glucemia y potasemia normales, estabilizó la presión arterial y recuperó los ciclos menstruales.

Adrenal carcinoma is a rare malignancy of poor prognosis. The most common clinical presentation is secondary to hormone production, while the development of symptomatic hypoglycemia is exceptional. We report the case of a 37 year old-woman admitted to hospital with severe hypoglycemia, hypertension, hypokalemia and amenorrhea. In the laboratory we found hypoglycemia, with low insulin levels, and androgen levels in tumor range. CT of abdomen and pelvis showed a heterogeneous lesion of solid appearance without a cleavage plane relative to liver parenchyma, and intense contrast enhancement. Retroperitoneal mass was removed, and the patient evolved without complications, blood glucose and potassium were normalized, blood pressure stabilized and menstrual cycles recovered.

A case of primary aldosteronism presenting as non-ST elevation myocardial infarction

No abstract available.

Síndrome de Cushing secundario a carcinoma de la glándula suprarrenal izquierda con metástasis hepáticas y trombosis tumoral masiva de la vena cava / Cushing´s syndrome due to a left adrenal cortical carcinoma with metastasis to the liver and a massive vena cava tumor thrombus

Se presenta el caso de una mujer de 47 años con cuadro clínico de siete meses de evolución caracterizado por aumento progresivo de peso, hipertensión arterial y diabetes mellitus de reciente aparición, hirsutismo facial y en tórax, alopecia frontal, alteraciones en la menstruación e hipopotasiemia. Se consideró el diagnóstico de síndrome de Cushing, por lo cual se iniciaron estudios e extensión para establecer su etiología. Durante su hospitalización presentó una evolución tórpida y falleció. En la autopsia clínica se encontró un carcinoma de la glándula suprarrenal izquierda, de 400 g, aproximadamente, con metástasis a hígado y trombosis masiva de la vena cava, lo que finalmente produjo su muerte.

A 47-year-old woman with a seven-month history of increasing weight, hypertension and recently diagnosed diabetes presented features of hirsutism, frontal baldness, amenorrhea and hypokalemia. These characteristics were considered diagnostic of Cushing´s syndrome, and studies were initialized to identify its etiology. During hospitalization, the patient presented a torpid evolution resulting in death. Clinical autopsy revealed a 400 g carcinoma in the left adrenal gland, liver metastasis and a massive vena cava tumor thrombus which was the final cause of death.

Hepatic metastasis from adrenocortical carcinoma fifteen years after primary resection

We report the case of a 73-year-old man who presented with an asymptomatic hepatic mass during investigation of mild chronic obstructive pulmonary disease by a plain chest radiograph, followed by ultrasonography, which revealed a solitary hepatic lesion measuring 7.1 cm x 6.5 cm x 5.8 cm in dimension. Fine- needle aspiration of the mass revealed malignant cells compatible with hepatocellular carcinoma. Interestingly, the patient had a left adrenalectomy and complete left nephrectomy in 1987, for a non-functioning left adrenocortical carcinoma [ACC]. The ACC was diagnosed as stage two, with no evidence of local invasion or distant metastases. No adjuvant therapy was recommended postoperatively. After a five-year follow-up, there was no evidence of ACC recurrence and the patient was declared cured from his ACC. The patient underwent a complete segmental resection of the right lobe of the liver successfully. The final diagnosis of the mass was a well-differentiated metastatic adrenocortical carcinoma

Aldosterone-Producing Adrenocortical Carcinoma without Hypertension

Although adrenocortical tumors are common, adrenocortical carcinomas are rare. Moreover, aldosterone-producing adrenocortical carcinomas without hypertension are exceedingly rare, with only two previously reported cases.

Hiperaldosteronismo primário: relato de dois casos / Primary hyperaldosteronism: report of two cases

The authors present two cases of Primary Hiperaldosteronism, caused by functioning adenoma of the adrenal's cortex. The two females patients presented classic symptoms of the Conn's disease, especially hypocalemia and hypertension. Both were operated and unilateral adrenalectomy was done, with excelent outcome in one and satisfactory in the other one. It is discussed many aspects related to the incidence, the problems with the diagnosis, indication and surgery treatment.

Giant adrenal myelolipoma associated with 21-hydroxylase deficiency: unusual association mimicking an androgen-secreting adrenocortical carcinoma / Mielolipoma adrenal gigante associado à deficiência da 21-hidroxilase: associação não usual simulando um carcinoma adrenocortical secretor de androgênios

The objective of this study was to describe a case of giant myelolipoma associated with undiagnosed congenital adrenal hyperplasia (CAH) due to 21-hydroxylase (21OH) deficiency. Five seven year-old male patient referred with abdominal ultrasound revealing a left adrenal mass. Biochemical investigation revealed hyperandrogenism and imaging exams characterized a large heterogeneous left adrenal mass with interweaving free fat tissue, compatible with the diagnosis of myelolipoma, and a 1.5 cm nodule in the right adrenal gland. Biochemical correlation has brought concerns about differential diagnosis with adrenocortical carcinoma, and surgical excision of the left adrenal mass was indicated. Anatomopathologic findings revealed a myelolipoma and multinodular hyperplasic adrenocortex. Further investigation resulted in the diagnosis of CAH due to 21OH deficiency. Concluded that CAH has been shown to be associated with adrenocortical tumors. Although rare, myelolipoma associated with CAH should be included in the differential diagnosis of adrenal gland masses. Moreover, CAH should always be ruled out in incidentally detected adrenal masses to avoid unnecessary surgical procedures.

O objetivo deste trabalho foi descrever um caso de mielolipoma gigante associado à hiperplasia adrenal congênita (HAC) por deficiência da 21-hidroxilase (21OH). Paciente do sexo masculino, 57 anos de idade, encaminhado por achado ultrassonográfico de massa adrenal esquerda. Investigação bioquímica revelou hiperandrogenismo e exames de imagem revelaram grande lesão sólida em adrenal esquerda de aspecto heterogêneo, entremeada de tecido gorduroso, compatível com diagnóstico de mielolipoma, e um nódulo de 1,5 cm na adrenal direita. Os achados bioquímicos sugeriam o diagnóstico de carcinoma adrenocortical, indicando cirurgia para retirada da massa adrenal esquerda. O anatomopatológico confirmou mielolipoma e hiperplasia multinodular do córtex adrenal. A investigação subsequente diagnosticou HAC por deficiência da 21OH. Concluiu-se que a HAC tem sido descrita em associação com tumores adrenocorticais. Apesar de raro, o mielolipoma associado à HAC deve ser incluído nas possibilidades diagnósticas de massa adrenal. Adicionalmente, a HAC deve ser sempre afastada nos casos de massa adrenal de achado incidental, evitando cirurgias desnecessárias.

Virilizing Adrenocortical Oncocytoma in a Child: A Case Report

Functioning adrenocortical oncocytomas are extremely rare and most reported patients are 40-60 yr of age. To our knowledge, only 2 cases of functioning adrenocortical oncocytomas have been reported in childhood. We report a case of functioning adrenocortical oncocytoma in a 14-yr-old female child presenting with virilization. She presented with deepening of the voice and excessive hair growth, and elevation of plasma testosterone and dehydroepiandrosterone sulfate. She had an adrenalectomy. The completely resected tumor composed predominantly of oncocytes without atypical mitosis and necrosis. A discussion of this case and a review of the literature on this entity are presented.

Spontaneous Rupture of a Functioning Adrenocortical Carcinoma

Adrenocortical carcinoma (ACC) is a rare malignancy with poor prognosis, and it can be classified as either a functional or nonfunctional tumor. Affected patients usually present with abdominal pain or with symptoms related to the mass effect or hormonal activity of the tumor. Several cases of spontaneously ruptured nonfunctional adrenocortical carcinoma have been reported, but no case of a spontaneous rupture of functioning adrenocortical carcinoma has been described. We report a functioning adrenocortical carcinoma that spontaneously ruptured during a work-up.

Symptomatic Hypocalcemia in Primary Hyperaldosteronism: A Case Report

The metabolic alterations caused by hyperaldosteronism are being increasingly recognized and have generated considerable interest among the medical fraternity. Hyperaldosteronism is suspected to have a pivotal role in the patho-physiology of congestive cardiac failure where it has been studied extensively. But its effects on calcium metabolism, parathyroid metabolism and renal handling of calcium are less well described. Recent experimental models have shed light into the roles played by previously unknown mechanisms in causing these metabolic alterations. We hereby report a case of primary hyperaldosteronism due to adrenal adenoma (Conn's syndrome) who presented with a myriad of clinical features including symptomatic hypocalcemia, significant weight loss along with uncontrolled hypertension for a prolonged period before eventually detected to have primary hyperaldosteronism. Surgical removal of the causative tumor resulted in prompt disappearance of all the symptoms and signs and regain of lost weight.

Functioning adrenocortical oncocytoma: a case report and review of literature.

Adrenocortical oncocytoma is very rare. Less than five functioning types of them are reported and most of the reported cases are incidentally found. We herein report a case of functioning adrenocortical oncocytoma of the left adrenal cortex in a young woman.

A Case of Cushing's Syndrome Presenting as Endometrial Hyperplasia

We describe here the case of a 39-year-old woman with a cortisol-producing adrenal adenoma and she presented with endometrial hyperplasia and hypertension without the specific characteristics of Cushing's syndrome. The patient had consulted a gynecologist for menometrorrhagia 2 years prior to her referral and she was diagnosed with endometrial hyperplasia and hypertension. Her blood pressure and the endometrial lesion were refractory despite taking multiple antihypertensives and repetitive dilation and curettage and progestin treatment. On admission, the clinical examination revealed mild central obesity (a body mass index of 22.9 kg/m2, a waist circumference of 85 cm and a hip circumference of 94cm), but there was no hirsutism and myopathy. She showed impaired glucose tolerance on an oral glucose tolerance test. The biochemical hypercortisolemia together with the prolactin and androgen levels were evaluated to explore the cause of her anovulation. Adrenal Cushing's syndrome was confirmed on the basis of the elevated urinary free cortisol (454 microgram/24h, normal range: 20-70) with a suppressed ACTH level (2.0 pg/mL, normal range: 6.0-76.0) and the loss of circadian cortisol secretion. A CT scan revealed a 3.1 cm, hyperechoic, well-marginated mass in the left adrenal gland. Ten months post-adrenalectomy, the patient had unintentionally lost 9 kg of body weight, had regained a regular menstrual cycle and had normal thickness of her endometrium.

Síndrome de Cushing subclínica em populações de risco: [revisão] / Subclinical Cushing's syndrome in populations at risk: [review]

Os incidentalomas de adrenais (IA) são tumores freqüentes em humanos. A síndrome de Cushing (SC) endógena é rara e os adenomas de adrenais são responsáveis por 10 por cento dos casos de SC. A SC subclínica ocorre em IA com dinâmica do cortisol anormal e ausência de fenótipo característico de hipercortisolismo. A prevalência média de SC subclínica em IA é de 9 por cento. Dados de pequenas séries indicam que 20 por cento dos IA desenvolvem alterações bioquímicas quando acompanhados por 10 anos. A evolução da SC subclínica parece ser benigna, raramente ocorrendo aumento da massa e evolução para a SC clinicamente manifesta. Os incidentalomas e a SC subclínica têm sido correlacionados aos componentes da síndrome metabólica, especialmente ao diabetes mellitus do tipo 2. Embora o número de pacientes avaliados ainda seja pequeno, os estudos disponíveis demonstram que o tratamento do hipercortisolismo resulta em melhor controle metabólico e da pressão arterial. Esses achados levaram alguns autores a pesquisar a presença de SC subclínica em pacientes com diagnóstico prévio de diabetes mellitus. Os estudos realizados utilizando diferentes abordagens diagnósticas mostraram que nesse grupo de pacientes a incidência de SC subclínica é maior do que na população geral.

Based on autopsy studies, adrenal masses are among the most common tumors in humans. Endogenous Cushing's syndrome (CS) is unusual and adrenal adenomas account for 10 percent of all cases of CS. Patients with subclinical CS (SCS) present abnormal cortisol dynamics without obvious manifestations. The prevalence of hypercortisolism in clinically inapparent adrenal masses has been reported as 9 percent. Data from several small series of patients indicate that fewer than 20 percent develop hormone overproduction when followed for up to 10 years. Follow-up of patients with subclinical CS suggests that rarely masses increase in size or progress to overt CS. Adrenal incidentalomas and subclinical CS are related to metabolic disorders, in special to type-2 diabetes. The scarce available data suggest that treatment of hypercortisolism correct the metabolic abnormalities and blood pressure. Some studies evaluating the prevalence of subclinical CS in overweight type-2 diabetes patients suggest that it is considerably higher in populations at risk than in the general population.

Subclinical Cushing's syndrome: [review]

Subclinical Cushing's syndrome (CS) is attracting increasing interest since the serendipitous discovery of an adrenal mass has become a rather frequent event owing to the routine use of sophisticated radiologic techniques. Cortical adenoma is the most frequent type of adrenal incidentaloma accounting for approximately 50 percent of cases in surgical series and even greater shares in medical series. Incidentally discovered adrenal adenomas may secrete cortisol in an autonomous manner that is not fully restrained by pituitary feedback, in 5 to 20 percent of cases depending on study protocols and diagnostic criteria. The criteria for qualifying subclinical cortisol excess are controversial and presently there is no consensus on a gold standard for the diagnosis of this condition. An increased frequency of hypertension, central obesity, impaired glucose tolerance, diabetes and hyperlipemia has been described in patients with subclinical CS; however, there is still no clear demonstration of the long-term complications of this condition whose management remains largely empirical. Either adrenalectomy or careful observation associated with treatment of the metabolic syndrome have been suggested as treatment options.

A síndrome de Cushing subclínica (SCS) tem atraído interesse cada vez maior desde que a descoberta casual de uma massa adrenal se tornou um evento freqüente devido ao emprego rotineiro de técnicas sofisticadas de imagem. O adenoma cortical é o tipo mais freqüente de incidentaloma adrenal, correspondendo a cerca de 50 por cento dos casos em séries cirúrgicas e até mais do que isso em séries médicas. Adenomas adrenais descobertos incidentalmente podem secretar cortisol de maneira autônoma ou não controlada totalmente pelo feedback hipofisário, em 5 a 20 por cento dos casos, dependendo do protocolo de estudo e dos critérios diagnósticos. Os critérios para qualificar um excesso subclínico de cortisol são controversos e atualmente não existe consenso a respeito de "padrão ouro" para o diagnóstico dessa condição. Em pacientes com SCS, tem sido descrita uma freqüência elevada de hipertensão, obesidade central, intolerância à glicose, diabetes e hiperlipemia; entretanto, ainda não existe uma evidente demonstração de complicações a longo prazo dessa condição, cujo manejo permanece amplamente empírico. Tanto a adrenalectomia como a observação cuidadosa, associada com o tratamento da síndrome metabólica, têm sido sugeridos como opções terapêuticas.

Hiperaldosteronismo primário causado por aldosteronoma: problemas no diagnóstico etiológico / Primary aldosteronism caused by aldosteronoma: problems in the etiologic diagnosis

O hiperaldosteronismo primário (HAP) representa importante causa de hipertensão arterial secundária, potencialmente curável, que tem recebido atenção recente em função do aumento de sua prevalência desde a introdução do rastreamento pelo uso da relação aldosterona/atividade plasmática de renina. Apresentamos caso de HAP causado por provável aldosteronoma, coexistente com adenoma adrenal não-funcionante contra-lateral, o que dificultou o diagnóstico etiológico. Discutimos as formas mais apropriadas de rastrear, confirmar o diagnóstico de HAP e diferenciar as suas diversas etiologias, com destaque para o papel do cateterismo de adrenais no diagnóstico diferencial definitivo entre aldosteronoma e hiperaldosteronismo idiopático, com implicações no sucesso terapêutico.

Primary aldosteronism (PA) represents an important cause of secondary hypertension, potentially curable, and it has been receiving particular attention due to its increasing prevalence, after the beginning of the use of plasma aldosterone concentration to plasma renin activity ratio as a screening method. We present a case of PA caused by an aldosteronoma associated with a contralateral nonfunctioning adrenal adenoma, which resulted in difficulties in the final diagnosis. We discuss the most appropriated tests to screen, confirm the diagnosis of PA and define the etiology of the disorder, especially the adrenal veins sampling to distinguish the aldosteronoma and idiopathic hyperaldosteronism and to guide successful treatment.

Functioning adrenocortical carcinoma with superior vena cava and upper airway obstructions.

BACKGROUND: Adrenocortical carcinoma (ACC) is one of the most aggressive endocrine malignancies with a dismal prognosis. Typically, the tumor is large and has regional invasion or distant metastasis at initial presentation. OBJECTIVE: To describe an unusual case of functioning ACC presenting with superior vena cava (SVC) and upper airway obstruction. MATERIAL AND METHOD: A 23-year-old man with cushingoid appearance was evaluated for a neck mass and SVC syndrome. Hormonal assessment and neck mass biopsy including immunohistochemistry study were performed RESULTS: Cushing's syndrome was confirmed by elevated 24-hr urinary free cortisol and no suppressible cortisol level after standard low dose (2 mg/day) of dexamethasone suppression test. Computerized tomography (CT) study revealed a huge left suprarenal mass and multiple mediastinal lymph nodes compressing SVC and trachea. Histopathological findings of the neck mass were compatible with metastatic ACC. CONCLUSION: The present report describes a functioning ACC patient with an unusual metastatic site causing SVC and upper airway obstruction. His hospital course was progressively worsened due to peptic perforation and decompensated respiratory failure, which led him to expire.

Adenoma de Conn: uma causa de hipertensão e hipocalemia / Conn's adenoma: a cause of hypertension and hypokalemia

Hipertensão secundária corresponde aproximadamente a 5 a 10% das causas de hipertensão arterial e, entre elas, o hiperaldosteronismo primário apresenta uma incidência variável de 0,05 a 2% em hipertensos, com quadro característico de hipocalemia, produção aumentada de aldosterona, redução ou supressão da renina, relação aldosterona/renina elevada e alcalose metabólica. Descrevemos um caso de paciente com hipertensão arterial primária controlada, que apresentou na sua evolução um adenoma de supra-renal com piora dos níveis tensionais.