Carcinoma suprarrenal. Presentación de caso clínico

El carcinoma suprarrenal es una enfermedad muy poco frecuente de presentación clínica poco específica, donde los síntomas por la propia neoplasia son los predominantes. El objetivo de esta publicación es presentar un caso clínico jerarquizando los estudios de imagen para el diagnóstico y la planificación de la táctica para la cirugía.

Adrenal carcinoma is a very rare disease with nonspecific clinical presentation, where symptoms from the neoplasia itself are predominant. The aim of this publication is to present an uncommon clinical case, emphasizing the role of imaging studies in diagnosis and surgical strategy planning.

O carcinoma adrenal é uma doença muito rara, com apresentação clínica inespecífica onde predominam os sintomas decorrentes da própria neoplasia. O objetivo desta publicação é apresentar um caso clínico infrequente priorizando exames de imagem para diagnóstico e planejamento de táticas cirúrgicas.

CT features of primary adrenal lymphoma / 实用放射学杂志

Objective To analyze the CT features of primary adrenal lymphoma (PAL)in order to improve the diagnosis of the disease.Methods Clinical and CT findings of 1 1 patients with pathologically confirmed PAL were retrospectively analyzed.Results 18 lesions (10 on the right side,and 8 on the left)were found in all 11 cases of PAL (bilateral lesions in 7 cases).The maximum diameter ranges of the lesions were from 3.8 cm to 12.0 cm (M ± SD:6.5±2.3 cm).The shapes of the lesions were shown as round (2/18),oval (9/18)or irregular (7/18).The plain CT showed all lesions with isodensity or lowGdensity,and the CT attenuation value ranged from 24.5 to 46.3 HU (mean 33.6±5.7 HU).The contrastGenhanced CT showed 16 lesions with slightGmoderate and gradual enhancement,1 lesion with nonenhancement and other 1 with severe enhancement.The CT value of the lesions ranged from 24.9 to 71.4 HU (M±SD:45.1 ± 12.1 HU)in arterial phase and 23.8 to 7 9.9 HU (M±SD:5 5.0±1 3.4 HU)in venous phase.The cystic degeneration in 8 lesions,infiltration of peripheral organs and vessels in 8 lesions,and peritumoral lymphadenectasis in 1 lesion were seen.In the 1 1 cases with 4－48 month followGup after chemotherapy,9 lesions decreased or disappeared,and other 2 decreased first but then increased.Conclusion PAL predominantly occurs in the bilateral adrenal glands and represents isoGlow density soft tissue mass on plain CT.Contrast enhanced CT shows the the solid parts of lesions mostly with mild to moderate gradual enhancement.In addition,the larger lesions are prone to have cystic degeneration and invade surrounding tissues and organs.

Hypo-androgen adrenocortical oncocytoma: 1 case report and literature review / 中华泌尿外科杂志

Objective To analysis the clinical features,diagnosis,treatment and prognosis of adrenal eosinophilic tumor with low testosterone levels.Methods The clinical data of a 22 years old male patient with adrenal eosinophilic tumor and low testosterone levels was analyzed.Blood pressure was 151/88 mmHg.The patient got bilateral gynecomastia.His bilateral testicular was soft and became smaller,with short penisr.Endocrine examination results showed:Estradiol 666 pg/ml,Prolactin 19.08 ng/ml,Testosterone 0.18 ng/ml,follicle stimulating hormone ＜ 0.2 U/L.The CT showed the mass density of soft tissue in the left adrenal region with diameter 7 cm,which was inhomogeneous and enhanced.There were many small vessels enhanced in the CT arterial phase,and the blood flow in the tumor was abundant.Clinical diagnosis of left adrenal tumor was pheochromocytoma.The patient underwent laparoscopic left adrenal tumor resection.The left adrenal gland was located in the superior pole of the left kidney,and there was an independent supply of the artery.Results Pathological result showed the tumor weigh was 60 g,7 cm in diameter and brown in section.The tumor cells were arranged in solid nests or acini,with more eosinophilic granules in cytoplasm.The nuclei was round and the nucleoli was located in the center,had clusters of pleomorphic and clustered cells.The tumor was wrapped in a thick fibrous envelope,mainly consisted of eosinophils,granulation tissue.There was no necrosis,mitosis,and vascular invasion.Immunohistochemical staining showed that the expression of CD56 and syn protein was positive.Pathological diagnosis was left adrenal eosinophilic tumor.After 4 months,the blood testosterone levels rose to 3.90 ng/ml,the blood pressure returned to normal (118/75 mmhg).The estradiol (21 pg/ml) was significantly inhibited.The patient began to appear beards and breasts became smaller.There were no signs of clinical or imaging recurrence.After 16 months follow-up,serum testosterone was 4.68 ng/ml and serum estrogen levels dropped to 33 pg/ml.Semen routine showed no sperm.Conclusions The clinical morbidity of functional adrenocortical oncocytoma with low testosterone levels and high estradiol levels is low.The pathological components are mainly eosinophilic granulation tissue.The adrenocortical oncocytoma are rare and preoperative diagnosis is difficult.Clinical manifestation,imaging examination and adrenal biochemistry examination should be considered to determine the localization and qualitative of tumor.Minimally invasive surgery is an effective treatment.The close follow-up after operation is essential.

Cirugía laparoscópica de quistes adrenales: resultados de una serie de 18 pacientes / Laparoscopic surgery of adrenal cysts: results of a series of 18 patients

Introduction: Adrenal cysts have an incidence of 0.064 percent to 0.18 percent at autopsy. Aim: To show our experience in 18 patients with an adrenal cyst operated by laparoscopy. Material and Methods: The series consisted of 18 patients operated, in a series of 344 laparoscopic adrenalectomy performed between 1993 and 2011. The age range was 20 to 61 years with an average of 38 years, 11 women and 7 men. Results: Thirteen cysts were left and 5 were right sided. The lesion size varied between 4.5 and 12.5 cm, with an average of 9.2 cm. Eight patients complained of abdominal discomfort and in the remaining 12 patients there were no signs or symptoms of clinical suspicion. The surgery performed was a laparoscopic decortication-marsupialization in 11 patients, laparoscopic adrenalectomy in 8 cases and partial adrenalectomy in 1 case. Mean operative time was 83.1 minutes (30-180 minutes), and mean hospital stay was 36 hours. Intraoperative complications occurred in 2 patients: 1 diaphragm injury and one renal vein injury, repaired in the same surgery. Postoperative complications occurred in 2 patients, both Clavien 3a, treated by conservative management. Conclusion: Small and non-functional lesions require observation. Partial or total laparoscopic adrenalectomy is indicated in large lesions or in functional and suspected malignant lesions.

Introducción: Los quistes suprarrenales tienen una incidencia de 0,064 por ciento a 0,18 por ciento en autopsias. El objetivo de este trabajo es mostrar nuestra experiencia en 18 pacientes portadores de un quiste adrenal operados por vía laparoscópica. Material y Métodos: La serie está constituida por 18 pacientes, de una serie de 344 adrenalectomías laparoscópicas realizadas entre los años 1993 y 2011. El rango de edad fue de 20 a 61 años, con un promedio de 38 años, 11 mujeres y 7 hombres. Resultados: Trece quistes eran del lado izquierdo y 5 del derecho. El tamaño de la lesión varió entre 4,5 y 12,5 cm, con un promedio de 9,2 cm. En 8 pacientes hubo molestias abdominales vagas y en los restantes 12 pacientes no hubo signos ni síntomas de sospecha clínica. La cirugía realizada fue una decorticación-marsupialización laparoscópica en 11 pacientes, adrenalectomía laparoscópica en bloque en 8 casos y adrenalectomía parcial en 1 caso. El tiempo operatorio promedio fue de 83,1 min (30-180 min), y el tiempo medio de hospitalización fue de 36 h. Complicaciones intraoperatorias ocurrieron en 2 pacientes: 1 lesión de diafragma y 1 lesión de vena renal, reparadas en el mismo acto quirúrgico. Complicaciones postoperatorias ocurrieron en 2 pacientes, ambas Clavien 3a y de manejo conservador. Conclusión: Las lesiones pequeñas y no funcionantes requieren observación. La adrenalectomía laparoscópica parcial o total está indicada en lesiones de gran tamaño, con importante compromiso de la glándula o ante la sospecha de lesión funcionante o malignidad.

Primary Mature Cystic Teratoma Mimicking an Adrenal Mass in an Adult Male Patient

Teratomas are bizarre neoplasms derived from embryonic tissues that are typically found only in the gonadal and sacrococcygeal regions of adults. Primary retroperitoneal teratomas are rare and present challenging management options. We report a case of a unilateral primary retroperitoneal mature cystic teratoma mimicking an adrenal mass in a 54-year-old male patient. Complete resection of the adrenal mass was performed by the flank approach by using the 11th rib resection. Because of the risk of malignancy, follow-up radiographic studies were performed to ensure the oncologic efficacy of resection. The patient has been free of recurrence for longer than 12 months.

Diagnóstico e tratamento das massas adrenais clinicamente silenciosas - revisão sistemática de literatura / Diagnoses and treatment of clinically unapparent adrenal masses - systematic literature review

Introdução: Massas adrenais clinicamente silenciosas, diagnosticadas sem intenção, incidentalmente, durante exame de imagem realizado para outras condições clínicas ("incidentaloma") têm sido cada vez mais encontradas devido ao constante progresso dos métodos de imagem e de sua indicação relativamente elástica. São inúmeras as causas, diagnósticos e tratamentos dessas massas, levando o médico a definir se a massa é hormonalmente ativa e se há risco de a lesão ser maligna. Entretanto os métodos para esclarecimento dessas questões ainda não estão bem definidos. Objetivo: Avaliar as melhores formas de diagnóstico, tratamento e seguimento da lesão incidental de adrenal. Método: Foi realizada uma revisão sistemática da literatura até outubro de 2004, analisando seu grau de evidência. Resultados: Foram encontrados dois trabalhos de revisão sistemática que selecionaram e estudaram artigos até setembro de 2003 e, então, adicionados ao estudo mais 28 artigos provenientes de revisão bibliográfica sistemática até outubro de 2004. Conclusões: Em geral os "incidentalomas" são não funcionantes, mas a avaliação endócrina demonstrou que não é raro o achado de hiperfunção hormonal subclínica, reforçando a necessidade de dosagem de certas substâncias, como metanefrinas, realização do teste de supressão de dexametasona em baixas dosagens e mensuração da relação da aldosterona plasmática/atividade plasmática da renina. "Incidentalomas" não funcionantes menores de 4cm devem ser observados entre 4 e 6cm devem ser analisados por suas características de imagem maiores de 6 cm devem ser operados. "Incidentalomas" funcionantes devem ser submetidos à adrenalectomia. Massas adrenais não operadas devem ser acompanhadas por dois anos, por meio de exames de imagem e de função.

Comparison of Laparoscopic Adrenalectomy with Open Adrenalectomy for Adrenal Tumor / 대한내시경복강경외과학회지

PURPOSE: The definite indications of laparoscopic adrenalectomy (LA) and the limitations of minimally invasive surgery have yet to be determined. To verify the benefit and safety of LA, we compared the results of LA with those of open adrenalectomy (OA) and we further analyzed the clinical results of LA in accordance with the time period of performing this surgery. METHODS: We retrospectively reviewed 69 patients who received adrenalectomy between 1997 and 2008. We compared LA with OA. The LA was divided into subsets of the early and late groups, and the transperitoneal approach and retroperitoneal approach groups, and we compared and analyzed the results of each group, along with the results of the OA and LA groups. For each of the groups, we analyzed the following factors; age, gender, tumor size, tumor location, the operative time, the time under anesthesia, the amounts of blood loss and transfusion, the time to first oral intake, the length of the postoperative hospital stay and the complications. RESULTS: LA (25 cases), as compared to OA (20 cases), showed better results for the amount of transfusion, the time to first oral intake, the length of the postoperative hospital stay and the complication rates (p=0.032; p=0.017; p=0.02). As for CA (4 cases), the time to first oral intake and the length of the postoperative hospital stay were significantly longer than that of LA (p=0.001; p=0.021). LA done in the late period demonstrated less blood loss and a shorter time to first oral intake as compared to the LA of the early period (p=0.032; p=0.019). There were no significant statistical differences between the results of the peritoneal or retroperitoneal approaches. CONCLUSION: LA has the merits of a shortening hospital stay and decreased complication. Furthermore, as the experience with this type of surgery accumulates, these merits are likely to become stronger. Thus, surgeons are expected to carefully decide on choosing the surgical methods by fully understanding the benefits and indications of LA.

Extramedullary Plasmacytoma Involving the Bilateral Adrenal Glands on MR Imaging

We report here on a 64-year-old woman with extramedullary plasmacytoma involving the bilateral adrenal glands. Primary adrenal extramedullary plasmacytoma is extremely rare and only three cases of extramedullary plasmacytoma in the unilateral adrenal gland have currently been reported on. This case is of interest in that the bilateral adrenals were involved. In this article, we present the MRI findings and we briefly review the relevant literature.

The Comparison of Laparoscopic Adrenalectomy with Open Adrenalectomy

PURPOSE: The purpose of our study was to compare the outcomes of patients who had undergone a conventional open adrenalectomy (OA) with those who had undergone a laparoscopic adrenalectomy (LA). METHODS: We retrospectively reviewed 66 patients who underwent an adrenalectomy between 1990 and 2005. The study group was comprised of 41 laparoscopic cases with 25 open adrenalectomy cases comprising the control group. The parameters studied included the operating times, transfusion volumes, time to resumption of a soft diet, total frequency of analgesics, time to return to free ambulation and length of hospital stay in both the OA and LA groups. RESULTS: No mortality was observed in either the OA or LA groups. The operating times were, on average, 203.1+/-64.5 and 158.2+/-76.4 minutes in the OA and LA group, respectively (P=0.011). 10 cases in the OA group needed a transfusion (average: 438.52+/-687.57 ml), but two cases including one require conversion to a celiotomy, due to a right renal vein injury, needed a transfusion (average: 23.41+/-110.63 ml)(P=0.004). The patients of the OA and LA groups began soft diets on the 4.8+/-1.1 (3~7 days) and 2.7+/-1.5 postoperative days (1~8 days), respectively (P=0.004). Total frequencies of analgesics were 9.5+/-6.5 and 4.4+/-4.7 in the OA and LA groups, respectively (P=0.001). The times needed to return to free ambulation were 7.6+/-3.8 and 4.3+/-2.3 days in the OA and LA groups, respectively (P= 0.000). Postoperative hospital stays were 16.3+/-7.5 and 7.3+/-2.3 days in the OA and LA groups, respectively (P=0.000). CONCLUSION: An LA appears to be a safe and effective approach for patients with various adrenal pathologies and large sized adrenal lesions. We expect the indications for an LA may be extended to large adrenal tumors as well as primary or metastatic malignant adrenal lesions if the oncologic principles are obeyed.

Application of Laparoscopy in Adrenal Surgery / 中国微创外科杂志

Objective To evaluate the clinical value of laparoscopy in adrenal surgery.Methods From December 2000 to May 2006,86 cases of adrenal space-occupying lesion received laparoscopic adrenalectomy via transperitoneal(n=1),retroperitoneal(n=81) and hand-assisted transperitoneal(n=4) approach,respectively.Results All the operations were successful without conversion to open surgery and severe complications.The mean operative time was 72 min(range,50-175 min).The mean blood loss was 54 ml(range,15-120 ml).The postoperative hospital stay was 6.3 d(range,5-8 d).Imaging examinations revealed no tumor recurrence and metastasis during the mean follow-up period of 26.5 months(range,2-65 months)in 86 patients.The symptoms of patients with functional tumor was alleviated or disappeared.Conclusions Laparoscopic adrenalectomy has advantages of minimal invasion,less blood loss,and quicker recovery,and it should be the fist choice for most adrenal space-occupying lesions.

A Case of Adrenocortical Oncocytoma / 대한내분비학회지

Oncocytomas are neoplasms, histologically are composed of epithelial cells, with abundant, acidophilic and granular cytoplasm. Electron microscopic studies of oncocytomas have shown that the cytoplasm of oncocytes is packed with mitochondria. The adrenal gland is a very rare anatomical site for oncocytomas, and to the best of our knowledge, only thirty-six cases of adrenal oncocytomas have been described. Herein, a case of a large adrenal mass in a forty-year-old man, which was incidentally detected by abdominal ultrasonography, is presented. This patient demonstrated no clinical manifestation associated with adrenal hyperfunction. Hormonal studies showed no abnormal findings, except for a mild elevation of the 24-hour urinary VMA level. Abdominal computed tomography with enhancement revealed a large, well-defined left adrenal mass, measuring 5.0x.2 x.0cm. The patient underwent a left adrenalectomy, and a light microscopic examination confirmed an adrenocortical oncocytoma, with characteristic oncocytes and polygonal, abundant, eosinophilic and granular cytoplasm. The tumor cells were positive for cytokeratin and vimentin as well as S-100, but negative for chromogranin on immunohistochemical staining. An electron microscopic examination demonstrated closely packed mitochondria, containing intramitochondrial inclusions. After surgery, there was no evidence of a recurrent or distant metastatic disease at the 5 month follow-up. In summary, an extremely rare case of a man with an adrenocortical oncocytoma is reported, which was confirmed by histological examinations, including electron microscopy.

Value of 3D DCE MRA in the Diagnosis of Adrenal Diseases and Renal Diseases / 中国医师杂志

Objective To evaluate the value of 3-dimensional dynamic contrast-enhanced magnetic resonance angiography (3D DCE MRA) in the diagnosis of adrenal and renal diseases.Methods 3D DCE MRA was performed on 22 patients with adrenal neoplasm,23 patients with renal neoplasm and 2 patients with stenosis of renal artery. Comparison with surgical findings or DSA was made.Results 3D DCE MRA clearly reflected the vascular anatomy,satisfied diagnostic demands.Simultaneously,The extravascular lesions were also detected.Conclusion The 3D DCE MRA is a reliable non-damaged imaging diagnostic method.

CT Diagnosis of Adrenal Myelolipoma / 实用放射学杂志

Objective To analysis the CT features and differential points of adrenal myelolipoma.Methods The CT and clinical information of 9 adrenal myelolipomas were collected.Results CT diagnosed 8 cases of adrenal myelolipoma except 1 case misdiagnosing as adenoma.All mass measuring 2.8～10.5 cm in diameter with clear edge,low attenuation value of fat and irregular linear shadow of soft tissure might be seen in mass.Conclusion CT is the best examination of diagnosing,which could show the position,component of the mass and organs around it.