Artificial intelligence with a deep learning network for the quantification and distinction of functional adrenal tumors based on contrast-enhanced CT images.

Background: Functional adrenal tumors (FATs) are mainly diagnosed by biochemical analysis. Traditional imaging tests have limitations and cannot be used alone to diagnose FATs. In this study, we aimed to establish an artificially intelligent diagnostic model based on computed tomography (CT) images to distinguish different types of FATs. Methods: A cohort study of 375 patients diagnosed with hyperaldosteronism (HA), Cushing's syndrome (CS), and pheochromocytoma in our center between March 2015 and June 2020 was conducted. Retrospectively, patients were randomly divided into three data sets: the training set (270 cases), the testing set (60 cases), and the retrospective trial set (45 cases). An artificially intelligent diagnostic model based on CT images was established by transferring data from the training set into the deep learning network. The testing set was then used to evaluate the accuracy of the model compared to that of physicians' judgments. The retrospective trial set was used to evaluate the quantification and distinction performance. Results: The deep learning model achieved an average area under the receiver operating characteristic (ROC) curve (AUC) of 0.915, and the AUCs in all three FAT types were greater than 0.882. The AUC of the model tested on the retrospective dataset reached above 0.849. In the quantitative evaluation of tumor lesion area recognition, the diagnostic model also obtained a segmentation Dice coefficient of 0.69. With the help of the proposed model, clinicians reached 92.5% accuracy in distinguishing FATs, compared to 80.6% accuracy when using only their judgment (P<0.05). Conclusions: The result of our study shows that the diagnostic model based on a deep learning network can distinguish and quantify three common FAT types based on texture features of contrast-enhanced CT images. The model can quantify and distinguish functional tumors without any endocrine tests and can assist clinicians in the diagnostic procedure.

Fibroblasts mediate the angiogenesis of pheochromocytoma by increasing COX4I2 expression.

Objective: Our previous work found COX4I2 was associated with angiogenesis in pheochromocytoma. The purpose of this study was to explore the role of COX4I2 in regulating angiogenesis in pheochromocytoma. Methods: Distribution of COX4I2 was evaluated by scRNA-seq in one case of pheochromocytoma and the findings were verified by immunostaining. COX4I2 was further knocked down in target cells. Changes of angiogenesis-related genes were evaluated by qPCR in target cells. Results: The scRNA-seq revealed high mRNA expression of COX4I2 in fibroblasts rather than tumor cells. Immunostaining of COX4I2 confirmed its distribution in fibroblasts. Knocking down COX4I2 in NIH3T3 cell line led to significant reduction of angiogenesis-related genes, especially ANG1 and HGF. Conclusions: Fibroblasts mediate the angiogenesis of pheochromocytoma by increasing COX4I2 expression, possibly by affecting ANG1 and HGF.

Lateroconal fascia suspension facilitates retroperitoneal partial nephrectomy.

Background: As the development of various imaging techniques, the incidental detection of renal masses is increasing. Laparoscopic partial nephrectomy (LPN) is the current standard of treatment for renal carcinoma. Though the retroperitoneal laparoscopic partial nephrectomy (RLPN) become the prior choice, the edge of lateroconal fascia blocks the sight and make operation more challenging. Methods: Between October 2018 and December 2020, the clinical data of 28 cases diagnosed with renal cell carcinoma (RCC) in our hospital was collected and analyzed retrospectively. All patients underwent RLPN and for management of curtain effect, we performed lateroconal fascia suspension (LFS) procedure in all cases with prepared Hem-o-lock clip which bound with 2-0 suture. Results: RLPN for renal tumor was successfully performed in all cases with no conversions to open surgery and other interruptions. In all cases, the free edge of lateroconal fascia and peritoneum partially blocked the sight of surgeon. We managed the curtain effect successfully and got a satisfying field of view for subsequent surgical procedure. The median operation time was 142 [interquartile range (IQR), 110-164] min, median estimated blood loss was 93 (IQR, 50-100) mL. Median warm ischemia time was 29 (IQR, 22-30) min. Conclusions: LFS is useful for management of curtain effect. It is a simple, economical and less invasive technique and we can get better efficiency with little consumption.

High TNFSF13B expression as a predictor of poor prognosis in adrenocortical carcinoma.

BACKGROUND: Adrenocortical carcinoma (ACC) is an extremely rare malignant tumor with poor prognosis. Existing treatment options have limited effects, and new therapeutic targets urgently need to be discovered. TNFSF13B has been reported to be associated with the prognosis of clear cell renal cell carcinoma, but it has not been studied in ACC. METHODS: TNFSF13B expression was analyzed and compared between ACC tumors and normal tissues by using public datasets from TCGA and GTEx. Kaplan-Meier analysis was employed to evaluate survival, and Cox regression was employed to evaluate clinicopathologic features. The upstream and downstream regulatory mechanisms of TNFSF13B were also analyzed. GSEA was performed to explore the mechanisms of TNFSF13B in ACC. Finally, 14 ACC clinical samples were used to verify the relationships between TNFSF13B expression and disease-free survival (DFS) and overall survival (OS). RESULTS: TNFSF13B expression was significantly higher in ACC tissues than in normal tissues. The prognosis of ACC patients with high TNFSF13B expression was worse than that of patients with low TNFSF13B expression. High TNFSF13B expression was strongly correlated with poor prognosis, and TNFSF13B was a prognostic factor. TNFSF13B expression is modified by upstream miRNAs, methylation and ubiquitination, and downstream, it interacts with other proteins. GSEA showed that regulation of cholesterol biosynthesis by SREBP and SREBF, downstream signaling events of the B cell receptor (BCR) and activation of gene expression by SREBF and SREBP were significantly enriched in the TNFSF13B high-expression phenotype. Clinical samples confirmed that TNFSF13B expression was significantly associated with DFS but not with OS. CONCLUSIONS: TNFSF13B may be a potential prognostic molecular marker of poor survival in ACC patients, offering a new therapeutic target.

Diagnosis and Treatment of High-risk Pregnant Women With Cushing Syndrome Caused by Adrenal Tumor.

Introduction: The occurrence of pregnancy with Cushing syndrome (CS) is rare but with high risks, posing a great challenge to the clinical diagnosis and treatment of the disease. Case Description: From Aug 2016 to Aug 2019, we admitted two pregnant women with CS caused by adrenal tumors. After multidisciplinary consultation, they underwent emergency Cesarean section because of heart failure and severe hypoxemia, and finally delivered a living baby after adjuvant therapy. Both patients underwent retroperitoneal laparoscopic adrenectomy (RLA) 2.6 and 1.5 months postpartum to have the adrenal tumors removed successfully. The postoperative pathology confirmed the adrenal tumor as adrenocortical adenoma. Partial hormone replacement therapy was initiated postoperatively and withdrawn uneventfully 1 year after RLA in both patients, and both patients have recovered well. Conclusions: It is difficult to find CS in early pregnancy, and when it is detected in late pregnancy, it often poses a great risk because it is necessary to consider the safety of both mother and fetus, which requires multidisciplinary coordination and cooperation to positively adjust the cardiopulmonary function and internal environment after Cesarean section, knowing that timely RLA to remove the adrenocortical adenoma can effectively cure CS.

Propensity Score Matched Analysis Comparing Robotic-Assisted with Laparoscopic Posterior Retroperitoneal Adrenalectomy.

OBJECTIVES: To compare the perioperative outcomes between robotic posterior retroperitoneal adrenalectomy (RPRA) with laparoscopic posterior retroperitoneal adrenalectomy (LPRA) for adrenal tumors and to identify which group of patients may benefit from RPRA. METHODS: A total of 401 patients who fulfilled the inclusion criteria were collected and analyzed; among them, 86 and 315 patients underwent RPRA and LPRA, respectively. To adjust for potential baseline confounders, propensity score matching (PSM) was conducted at a 1:1 ratio. Patient demographics and perioperative outcomes were compared between the two groups. RESULTS: After matching, no differences were found between the two groups in patient demographics or tumor characteristics. The median length of postoperative stay (3 vs. 4 days, p = 0.001) was significantly shorter in the RPRA group, but this group also showed a higher median total hospitalization cost (8121.89 vs. 4107.92 $, p < 0.001). There was no difference in the median operative duration (100 vs. 110 min, p = 0.554), median estimated blood loss (50 vs. 50 ml, p = 0.730), transfusion rate (p = 0.497) or incidence of postoperative complications (p = 0.428). CONCLUSIONS: According to our research, RPRA leads to a shorter postoperative hospitalization stay but a higher total hospitalization cost than LPRA after propensity score matching.

The clinical experience of diagnosis and treatment on adrenal metastases (report of 55 cases) / 中华泌尿外科杂志

Objective To discuss the clinical characteristics of adrenal metastases,and summarize the experience of diagnosis and treatment.Methods From January 2008 to June 2018,the clinical data of 55 patients with adrenal metastases treated in our hospital were analyzed retrospectively.This study included 34 male patients and 21 female patients and the median age was 60 years old (ranged 55 to 84 years old).The median value of maximum diameter of adrenal metastases was 3 cm (ranged 1.9 to 10.3 cm);with 35 cases on the left side,13 cases right and 7 cases bilateral.The primary sites of malignant tumors were pancreas (18 cases,32.7％),lung (12 cases,21.8％),liver (6 cases,10.9％) and colorectum (6 cases,10.9％),respectively.Thirty-four cases were confirmed by pathology after adrenalectomy and 21 cases were confirmed by needle biopsy.Thirty cases were diagnosed synchronously with the primary tumor and 25 cases were metachronous.The median time from diagnosis of primary tumors was 13.3 months (ranged 2.0 to 97.4 months).42 cases of these 55 cases were diagnosed within one year.Treatment options for adrenal metastatic lesions included single adrenalectomy in 18 cases,adrenalectomy combined with radiotherapy 16 cases,single intravenous chemotherapy 10 cases,intravenous chemotherapy combined with non-operative treatment 10 cases and single radiotherapy 1 case.Results The main pathological types were adenocarcinoma (19 cases,34.5％),ductal adenocarcinoma (10 cases,18.2％),hepatocellular carcinoma (6 cases,10.9％) and clear cell carcinoma (4 cases,7.3％).Two cases were lost follow-up and the follow-up rate was 96％,the median follow-up time was 8 months (ranged 1 to 135 months).The median overall survival (OS) time of 55 patients was 5.3 months (ranged 1 to 134 months).The one-year survival rate was 23.6％ (13/55),the two-year survival rate was 12.7％ (7/55),the three-year survival rate was 9.1％ (5/55) and the five-year survival rate was 1.8％ (1/55).Conclusions Pancreatic cancer was the most common type of malignant tumor for adrenal metastases in our hospital.Most primary tumors and adrenal metastases were diagnosed synchronously or within one year.Comprehensive treatment with retroperitoneal adrenalectomy may improve the OS,however the overall prognosis is poor.