Adrenocortical neoplasm in a 2-year-old child: Clinical approach and diagnostic imaging.

Adrenocortical tumors in children and adolescents are rare and aggressive, accounting for only 0.2% of pediatric cancers, with most cases associated with Li-Fraumeni syndrome. The most common manifestation is virilization due to androgen excess. Imaging techniques are crucial in the diagnosis and management of pediatric adrenocortical carcinoma. CT and MRI are essential for differentiating between benign and malignant lesions and assessing tumor characteristics and extent. Correlating imaging findings with clinical and histopathological data is vital for optimal diagnosis and treatment, underscoring the need for a multidisciplinary approach to managing these rare but aggressive neoplasms. This report presents the case of a previously healthy 2-year-old boy who exhibited virilization symptoms and was diagnosed with adrenocortical carcinoma.

AI-guided identification of risk variants for adrenocortical tumours in TP53 p.R337H carrier children: a genetic association study.

Background: Adrenocortical tumours (ACT) in children are part of the Li-Fraumeni cancer spectrum and are frequently associated with a germline TP53 pathogenic variant. TP53 p.R337H is highly prevalent in the south and southeast of Brazil and predisposes to ACT with low penetrance. Thus, we aimed to investigate whether genetic variants exist which are associated with an increased risk of developing ACT in TP53 p.R337H carrier children. Methods: A genetic association study was conducted in trios of children (14 girls, 7 boys) from southern Brazil carriers of TP53 p.R337H with (n = 18) or without (n = 3) ACT and their parents, one of whom also carries this pathogenic variant (discovery cohort). Results were confirmed in a validation cohort of TP53 p.R337H carriers with (n = 90; 68 girls, 22 boys) or without ACT (n = 302; 165 women, 137 men). Findings: We analysed genomic data from whole exome sequencing of blood DNA from the trios. Using deep learning algorithms, according to a model where the affected child inherits from the non-carrier parent variant(s) increasing the risk of developing ACT, we found a significantly enriched representation of non-coding variants in genes involved in the cyclic AMP (cAMP) pathway known to be involved in adrenocortical tumorigenesis. One among those variants (rs2278986 in the SCARB1 gene) was confirmed to be significantly enriched in the validation cohort of TP53 p.R337H carriers with ACT compared to carriers without ACT (OR 1.858; 95% CI 1.146, 3.042, p = 0.01). Interpretation: Profiling of the variant rs2278986 is a candidate for future confirmation and possible use as a tool for ACT risk stratification in TP53 p.R337H carriers. Funding: Centre National de la Recherche Scientifique (CNRS), Behring Foundation, Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq).

Impact of Aging on the Morphology of the Adrenal Gland in Rats / Impacto del Envejecimiento en la Morfología de la Glándula Suprarrenal en Ratas

SUMMARY: Aging is an inevitable biological process that affects the function of all organs, including the adrenal gland, which is essential for producing steroid hormones that regulate metabolism, stress response, and immune activation. Understanding how aging affects the morphology of this gland is crucial to developing interventions to mitigate its adverse effects. Thus, this study aimed to describe the morphoquantitative alterations of the adrenal gland in senescent Sprague Dawley rats compared to adult rats. Twelve male rats were divided into 6 adult rats aged 6 months (group A) and 6 senescent rats aged 36 months (group S). Histopathological studies, quantification of collagen fibers types I and III, and stereological analysis were performed to determine the volume density (Vv), surface area (Sv), and number (Nv) of the nuclei of the zona fasciculata cells. Adrenal gland tissue from group S presented dysplasia, metaplasia, intracellular fat accumulation, fibrosis, blood vessel dilation, and increased presence of apoptotic cells. Capsule thickening and increased collagen type I were also observed. There was a significant decrease in Vv, Sv, and Nv of zona fasciculata nuclei in group S compared to group A. The results indicate that aging induces significant morphoquantitative changes in the adrenal gland, which could contribute to the decrease in glucocorticoid production and alterations in aldosterone and cortisol secretion observed in senescence. Understanding these alterations is crucial to developing interventions that mitigate the adverse effects of aging on the endocrine system.

El envejecimiento es un proceso biológico inevitable que afecta la función de todos los órganos, incluida la glándula suprarrenal, fundamental para la producción de hormonas esteroides que regulan el metabolismo, la respuesta al estrés y la activación inmunológica. Comprender cómo el envejecimiento afecta la morfología de esta glándula es crucial para desarrollar intervenciones que mitiguen sus efectos adversos. Así, el objetivo de este estudio fue describir las alteraciones morfocuantitativas de la glándula suprarrenal en ratas Sprague Dawley senescentes comparadas con ratas adultas. Se utilizaron 12 ratas macho, divididas en dos grupos: 6 ratas adultas de 6 meses de edad (grupo A) y 6 ratas senescentes de 36 meses de edad (grupo S). Se realizaron estudios histopatológicos, cuantificación de fibras de colágeno tipos I y III y análisis estereológicos para determinar la densidad de volumen (Vv), de superficie (Sv) y de número (Nv) de los núcleos de las células de la zona fasciculada. El tejido de la glándula suprarrenal del grupo S presentó displasia, metaplasia, acumulación de grasa intracelular, fibrosis, dilatación de vasos sanguíneos y mayor presencia de células apoptósicas. También se observó un engrosamiento de la cápsula y un incremento del colágeno tipo I. Hubo una disminución significativa en Vv, Sv y Nv de los núcleos de la zona fasciculada en el grupo S en comparación con el grupo A. Los resultados indican que el envejecimiento induce cambios morfocuantitativos significativos en la glándula suprarrenal, lo que podría contribuir a la disminución en la producción de glucocorticoides y alteraciones en la secreción de aldosterona y cortisol observadas en la senescencia. Comprender estas alteraciones es crucial para desarrollar intervenciones que mitiguen los efectos adversos del envejecimiento en el sistema endocrino.

Proteomic profiling of the extracellular matrix in the human adrenal cortex.

The extracellular matrix (ECM) comprises macromolecules that shape a complex three-dimensional network. Filling the intercellular space and playing a crucial role in the structure and function of tissues, ECM regulates essential cellular processes such as adhesion, differentiation, and cell signaling. In the human adrenal gland, composed of cortex and medulla surrounded by a capsule, the ECM has not yet been directly described, although its impact on the processes of proliferation and steroidogenesis of the adrenal cortex is recognized. This study analyzes the ECM of the adult human adrenal cortex, which was separated into outer fraction (OF) and inner fraction (IF), by comparing their proteomic profiles. The study discusses the composition, spatial distribution, and relevance of differentially expressed ECM signatures of the adrenal cortex matrisome on adrenal structure and function. The findings were validated through database analysis (cross-validation), histochemical, and immunohistochemical approaches. A total of 121 ECM proteins were identified and categorized into glycoproteins, collagens, ECM regulators, proteoglycans, ECM-affiliated proteins, and secreted factors. Thirty-one ECM proteins were identified only in OF, nine only in IF, and 81 were identified in common with both fractions. Additionally, 106 ECM proteins were reported in the Human matrisome DB 2.0, and the proteins differentially expressed in OF and IF, were identified. This study provides significant insights into the composition and regulation of the ECM in the human adrenal cortex, shedding light on the adrenal microenvironment and its role in the functioning, maintenance, and renewal of the adrenal gland.

Extracellular Matrix Protein Signatures of the Outer and Inner Zones of the Rat Adrenal Cortex.

This study analyzes the extracellular matrix (ECM) signatures of the outer (OF = capsule + subcapsular + zona glomerulosa cells) and inner fractions (IF = zona fasciculata cells) of the rat adrenal cortex, which comprise two distinct microenvironment niches. Proteomic profiles of decellularized OF and IF samples, male and female rats, identified 252 proteins, with 32 classified as ECM-component and ECM-related. Among these, 25 proteins were differentially regulated: 17 more abundant in OF, including Col1a1, Col1a2, Col6a1, Col6a2, Col6a3, Col12a1, Col14a1, Lama5, Lamb2, Lamc1, Eln, Emilin, Fbln5, Fbn1, Fbn2, Nid1, and Ltbp4, and eight more abundant in IF, including Col4a1, Col4a2, Lama2, Lama4, Lamb1, Fn1, Hspg2, and Ecm1. Eln, Tnc, and Nid2 were abundant in the female OF, while Lama2, Lama5, Lamb2, and Lamc1 were more abundant in the male IF. The complex protein signature of the OF suggests areas of tissue stress, stiffness, and regulatory proteins for growth factor signaling. The higher concentrations of Col4a1 and Col4a2 and their role in steroidogenesis should be further investigated in IF. These findings could significantly enhance our understanding of adrenal cortex functionality and its implications for human health and disease. Key findings were validated, and data are available in ProteomeXchange (PXD046828).

Proteomic profiling of the extracellular matrix in the human adrenal cortex

The extracellular matrix (ECM) comprises macromolecules that shape a complex three-dimensional network. Filling the intercellular space and playing a crucial role in the structure and function of tissues, ECM regulates essential cellular processes such as adhesion, differentiation, and cell signaling. In the human adrenal gland, composed of cortex and medulla surrounded by a capsule, the ECM has not yet been directly described, although its impact on the processes of proliferation and steroidogenesis of the adrenal cortex is recognized. This study analyzes the ECM of the adult human adrenal cortex, which was separated into outer fraction (OF) and inner fraction (IF), by comparing their proteomic profiles. The study discusses the composition, spatial distribution, and relevance of differentially expressed ECM signatures of the adrenal cortex matrisome on adrenal structure and function. The findings were validated through database analysis (cross-validation), histochemical, and immunohistochemical approaches. A total of 121 ECM proteins were identified and categorized into glycoproteins, collagens, ECM regulators, proteoglycans, ECM-affiliated proteins, and secreted factors. Thirty-one ECM proteins were identified only in OF, nine only in IF, and 81 were identified in common with both fractions. Additionally, 106 ECM proteins were reported in the Human matrisome DB 2.0, and the proteins differentially expressed in OF and IF, were identified. This study provides significant insights into the composition and regulation of the ECM in the human adrenal cortex, shedding light on the adrenal microenvironment and its role in the functioning, maintenance, and renewal of the adrenal gland.

Inflammatory Myofibroblastic Tumor in the Adrenal Gland: A Case Report.

Inflammatory myofibroblastic tumors (IMTs) were first described by Harold Brunn in 1939. IMTs are mainly found in the lungs and other sites of the body; hence, its occurrence in the adrenal gland is exceptional. In the literature, less than 10 cases of IMTs in the adrenal gland have been reported. The etiology of IMT remains unknown, with post-inflammatory changes and a neoplastic origin being proposed. We present a case of a 19-year-old woman and adrenal gland IMT. The patient presented with abdominal pain and low cardiac output without hypovolemic shock. Computed tomography revealed a tumor in the adrenal gland measuring 11.4 cm with extravasation of contrast medium within the tumor. Treatment included conservative management with selective embolization due to minimal invasion of the inferior artery of the adrenal gland. The patient was then discharged with possibility of future elective surgery. Four months later, the size of the tumor decreased to 6.3 cm, and her Eastern Cooperative Oncology Group physical status was 0. The Multidisciplinary Tumor Board suggested surgical management. The final histopathology report was compatible with an IMT of the adrenal gland, with the immunohistochemical report showing positivity for anti-actin muscle-specific and anti-actin smooth muscle and negativity for anaplastic lymphoma kinase. IMTs of the adrenal gland may be treated electively through multidisciplinary management together with interventional radiology and surgery, achieving a favorable outcome for the patient.

When the adrenals alert us to a systemic fungal disease.

We present a patient referred for investigation of adrenal insufficiency, confirmed due to disseminated paracoccidioidomycosis (PCM), with abdominal and central nervous system (CNS) involvement. Establishing the pathogenesis and immunological processes involved in chronic or latent infections by PCM has been challenging. Medical doctors caring for patients with immunodeficiencies should learn about these fungal infections to properly guide travel planning and have this possibility in the diagnostic arsenal when the patient returns from endemic areas. After 13 months of treatment, the patient showed good clinical evolution, and we repeated imaging exams, showing partial improvement of the preview lesions. Diagnosis and treatment can prevent catastrophic events.

Severe osteoporosis in a young man with bilateral Cushing's syndrome: a case report.

BACKGROUND: The diagnosis of Cushing's syndrome is challenging; however, through the clinical picture and the search for secondary causes of osteoporosis, it was possible to reach the diagnosis of the case reported. There was an independent, symptomatic ACTH hypercortisolism manifested by typical phenotypic changes, severe secondary osteoporosis and arterial hypertension in a young patient. CASE PRESENTATION: A 20-year-old Brazilian man with low back pain for 8 months. Radiographs showed fragility fractures in the thoracolumbar spine, and bone densitometry showed osteoporosis, especially when evaluating the Z Score (- 5.6 in the lumbar spine). On physical examination, there were wide violaceous streaks on the upper limbs and abdomen, plethora and fat increase in the temporal facial region, hump, ecchymosis on limbs, hypotrophy of arms and thighs, central obesity and kyphoscoliosis. His blood pressure was 150 × 90 mmHg. Cortisol after 1 mg of dexamethasone (24.1 µg/dL) and after Liddle 1 (28 µg/dL) were not suppressed, despite normal cortisoluria. Tomography showed bilateral adrenal nodules with more severe characteristics. Unfortunately, through the catheterization of adrenal veins, it was not possible to differentiate the nodules due to the achievement of cortisol levels that exceeded the upper limit of the dilution method. Among the hypotheses for the differential diagnosis of bilateral adrenal hyperplasia are primary bilateral macronodular adrenal hyperplasia, McCune-Albright syndrome and isolated bilateral primary pigmented nodular hyperplasia or associated with Carney's complex. In this case, primary pigmented nodular hyperplasia or carcinoma became important etiological hypotheses when comparing the epidemiology in a young man and the clinical-laboratory-imaging findings of the differential diagnoses. After 6 months of drug inhibition of steroidogenesis, blood pressure control and anti-osteoporotic therapy, the levels and deleterious metabolic effects of hypercortisolism, which could also impair adrenalectomy in the short and long term, were reduced. Left adrenalectomy was chosen, given the possibility of malignancy in a young patient and to avoid unnecessary definitive surgical adrenal insufficiency if the adrenalectomy was bilateral. Anatomopathology of the left gland revealed expansion of the zona fasciculate with multiple nonencapsulated nodules. CONCLUSION: The early identification of Cushing's syndrome, with measures based on the assessment of risks and benefits, remains the best way to prevent its progression and reduce the morbidity of the condition. Despite the unavailability of genetic analysis for a precise etiological definition, it is possible to take efficient measures to avoid future damage.

Histogram analysis in the differentiation between adrenal adenomas and pheochromocytomas: the value of a single measurement.

Objective: To assess the diagnostic accuracy of histogram analysis on unenhanced computed tomography (CT) for differentiating between adrenal adenomas and pheochromocytomas (PCCs). Materials and Methods: We retrospectively identified patients with proven PCCs who had undergone CT examinations between January 2009 and July 2019 at one of two institutions. For each PCC, we selected one or two adenomas diagnosed within two weeks of the date of diagnosis of the PCC. For each lesion, two readers scored the size, determined the mean attenuation, and generated a voxel histogram. The 10th percentile (P10) was obtained from the conventional histogram analysis, as well as being calculated with the following formula: P10 = mean attenuation - (1.282 × standard deviation). The mean attenuation threshold, histogram analysis (observed) P10, and calculated P10 (calcP10) were compared in terms of their diagnostic accuracy. Results: We included 52 adenomas and 29 PCCs. The sensitivity, specificity, and accuracy of the mean attenuation threshold were 75.0%, 100.0%, and 82.5%, respectively, for reader 1, whereas they were 71.5%, 100.0%, and 81.5%, respectively, for reader 2. The sensitivity, specificity, and accuracy of the observed P10 and calcP10 were equal for both readers: 90.4%, 96.5%, and 92.6%, respectively, for reader 1; and 92.3%, 93.1%, and 92.6%, respectively, for reader 2. The increase in sensitivity was significant for both readers (p = 0.009 and p = 0.005, respectively). Conclusion: For differentiating between adenomas and PCCs, the histogram analysis (observed P10 and calcP10) appears to outperform the mean attenuation threshold as a diagnostic criterion.

Objetivo: Avaliar a acurácia diagnóstica da análise por histograma na tomografia computadorizada (TC) sem contraste para a diferenciação entre adenomas adrenais e feocromocitomas (FCCs). Materiais e Métodos: Identificamos, retrospectivamente, pacientes com diagnóstico de FCC confirmado que foram submetidos a exames de TC entre janeiro de 2009 e julho de 2019 em duas instituições distintas. Para cada FCC, selecionamos um ou dois adenomas diagnosticados em até duas semanas da data do diagnóstico do FCC. Para cada lesão, dois leitores pontuaram o tamanho, determinaram a atenuação média e geraram um histograma com os voxels das imagens. O percentil 10 (P10) foi obtido a partir da análise convencional do histograma, além de ser calculado com a seguinte fórmula: P10 = atenuação média - (1,282 × desvio-padrão). O limiar de atenuação média, o P10 da análise por histograma (P10 observado) e o P10 calculado (P10calc) foram comparados em termos de acurácia diagnóstica. Resultados: Foram incluídos 52 adenomas e 29 FCCs. A sensibilidade, especificidade e acurácia do limiar de atenuação média foram de 75,0%, 100,0% e 82,5% para o leitor 1, respectivamente, e de 71,5%, 100,0% e 81,5% para o leitor 2, respectivamente. A sensibilidade, especificidade e acurácia do P10 observado e do P10calc foram idênticas para os dois leitores: 90,4%, 96,5% e 92,6%, respectivamente, para o leitor 1; e 92,3%, 93,1% e 92,6%, respectivamente, para o leitor 2. O aumento da sensibilidade foi significativo para ambos os leitores (p = 0,009 e p = 0,005, respectivamente). Conclusão: Para a diferenciação entre adenomas e FCCs, a análise por histograma (P10 observado ou P10calc) parece superar o limiar de atenuação média como critério diagnóstico.

Pathological Aspects and Immunohistochemical Evaluation of Troponin C in the Cardiovascular System of Dogs With Pheochromocytoma.

Functional pheochromocytomas secrete catecholamines and have been associated with cardiovascular lesions in dogs. This study aimed to describe the postmortem pathological findings in the cardiovascular system of dogs with pheochromocytoma and to evaluate the expression of cardiac troponin C in these dogs using immunohistochemical analysis. Twelve cases were identified, with a mean age of 10.6 years. The heart of all dogs was enlarged and with concentric hypertrophy of the left ventricular myocardium. Histological analysis showed cardiomyocyte necrosis and degeneration in the myocardium, with frequent bands of contraction, fibrosis, inflammation, and thickening of the medium-caliber arteries in the myocardium. There was a marked decrease or absence of immunolabeling in necrotic cardiomyocytes. We conclude that IHC for troponin C can be a useful tool for detecting myocardial necrosis in dogs with pheochromocytomas, including early cases of necrosis with only incipient cardiac changes where overt histologic abnormalities are not immediately apparent in the cardiomyocytes.

Prevalence of reported incidental adrenal findings in chest computerized tomography scans performed during the COVID-19 pandemic in a single center in Northeast Brazil.

Objective: We investigated the prevalence of adrenal incidentalomas (AIs) in a nonselected Brazilian population in chest computed tomography (CT) performed during the COVID-19 pandemic. Materials and methods: This was a retrospective cross-sectional observational study using chest CT reports from a tertiary in- and outpatient radiology clinic from March to September 2020. AIs were defined by changes in the shape, size, or density of the gland initially identified in the released report. Individuals with multiple studies were included, and duplicates were removed. Exams with positive findings were reviewed by a single radiologist. Results: A total of 10,329 chest CTs were reviewed, and after duplicate removal, 8,207 exams were included. The median age was 45 years [IQR 35-59 years], and 4,667 (56.8%) were female. Thirty-eight lesions were identified in 36 patients (prevalence 0.44%). A higher prevalence was observed with age, with 94.4% of the findings in patients aged 40 years and over (RR 9.98 IC 2.39-41.58, p 0.002), but there was no significant difference between the sexes. Seventeen lesions (44.7%) had more than 10 HU, and five lesions (12.1%) were more than 4 cm. Conclusion: The prevalence of AIs in an unselected and unreviewed population in a Brazilian clinic is low. The impact on the health system caused by AIs discovered during the pandemic should be small regarding the need for specialized follow-up.

Histogram analysis in the differentiation between adrenal adenomas and pheochromocytomas: the value of a single measurement / Análise por histograma para diferenciação entre adenomas da adrenal e feocromocitomas: o valor de uma medida única

Abstract Objective: To assess the diagnostic accuracy of histogram analysis on unenhanced computed tomography (CT) for differentiating between adrenal adenomas and pheochromocytomas (PCCs). Materials and Methods: We retrospectively identified patients with proven PCCs who had undergone CT examinations between January 2009 and July 2019 at one of two institutions. For each PCC, we selected one or two adenomas diagnosed within two weeks of the date of diagnosis of the PCC. For each lesion, two readers scored the size, determined the mean attenuation, and generated a voxel histogram. The 10th percentile (P10) was obtained from the conventional histogram analysis, as well as being calculated with the following formula: P10 = mean attenuation - (1.282 × standard deviation). The mean attenuation threshold, histogram analysis (observed) P10, and calculated P10 (calcP10) were compared in terms of their diagnostic accuracy. Results: We included 52 adenomas and 29 PCCs. The sensitivity, specificity, and accuracy of the mean attenuation threshold were 75.0%, 100.0%, and 82.5%, respectively, for reader 1, whereas they were 71.5%, 100.0%, and 81.5%, respectively, for reader 2. The sensitivity, specificity, and accuracy of the observed P10 and calcP10 were equal for both readers: 90.4%, 96.5%, and 92.6%, respectively, for reader 1; and 92.3%, 93.1%, and 92.6%, respectively, for reader 2. The increase in sensitivity was significant for both readers (p = 0.009 and p = 0.005, respectively). Conclusion: For differentiating between adenomas and PCCs, the histogram analysis (observed P10 and calcP10) appears to outperform the mean attenuation threshold as a diagnostic criterion.

Resumo Objetivo: Avaliar a acurácia diagnóstica da análise por histograma na tomografia computadorizada (TC) sem contraste para a diferenciação entre adenomas adrenais e feocromocitomas (FCCs). Materiais e Métodos: Identificamos, retrospectivamente, pacientes com diagnóstico de FCC confirmado que foram submetidos a exames de TC entre janeiro de 2009 e julho de 2019 em duas instituições distintas. Para cada FCC, selecionamos um ou dois adenomas diagnosticados em até duas semanas da data do diagnóstico do FCC. Para cada lesão, dois leitores pontuaram o tamanho, determinaram a atenuação média e geraram um histograma com os voxels das imagens. O percentil 10 (P10) foi obtido a partir da análise convencional do histograma, além de ser calculado com a seguinte fórmula: P10 = atenuação média - (1,282 × desvio-padrão). O limiar de atenuação média, o P10 da análise por histograma (P10 observado) e o P10 calculado (P10calc) foram comparados em termos de acurácia diagnóstica. Resultados: Foram incluídos 52 adenomas e 29 FCCs. A sensibilidade, especificidade e acurácia do limiar de atenuação média foram de 75,0%, 100,0% e 82,5% para o leitor 1, respectivamente, e de 71,5%, 100,0% e 81,5% para o leitor 2, respectivamente. A sensibilidade, especificidade e acurácia do P10 observado e do P10calc foram idênticas para os dois leitores: 90,4%, 96,5% e 92,6%, respectivamente, para o leitor 1; e 92,3%, 93,1% e 92,6%, respectivamente, para o leitor 2. O aumento da sensibilidade foi significativo para ambos os leitores (p = 0,009 e p = 0,005, respectivamente). Conclusão: Para a diferenciação entre adenomas e FCCs, a análise por histograma (P10 observado ou P10calc) parece superar o limiar de atenuação média como critério diagnóstico.

Laparoscopic adrenalectomy: comparison between pneumoperitoneum and the use of a laparoscopic lift device in dog cadavers / Adrenalectomia laparoscópica: comparação entre o pneumoperitônio e o uso de dispositivo paraliftlaparoscopy em cadáveres de cães

This study evaluated the feasibility of abdominal liftfor laparoscopic adrenalectomy and compared it with the conventional laparoscopic technique using pneumoperitoneum with medicinal CO2 in dog cadavers. The total surgical time (TST), adrenalectomy time (AT), and gland integrity after removal were evaluated. Thirty-eight adrenalectomies were performed in 19 cadavers. Regardless of the antimere, the TST was significantly lower in the CO2 procedures than in the lift laparoscopy procedures (P=0.001). When comparing the techniques between antimeres, the TST was significantly higher on the left side with lift laparoscopy than with CO2 (P=0.015) and similar between the techniques on the right side of the animals (P=0.086). In the comparison of AT, regardless of the execution side, no differences were observed between the techniques (P=0.05). The same was observed when AT was evaluated separately using antimeres (P=0.902). Of the 38 adrenals evaluated, 92.1% were removed in a single block, and 32.29% had a superficial lesion in the capsule. There was no difference between the groups in the removal capacity in a single block (P=0.340) and capsule integrity (P=0.287). Abdominal lift for laparoscopic adrenalectomy is a feasible technique in dog cadavers; however, it requires a longer surgical time than the conventional technique. The traction force used to elevate the abdominal wall must be evaluated.

O presente trabalho teve como objetivo avaliar a exequibilidade da adrenalectomia laparoscópica utilizando dispositivo de elevação da parede abdominal via liftlaparoscopy e comparar com a técnica laparoscópica convencional utilizando pneumoperitônio com CO2 medicinal em cadáveres de cães. Para isso, avaliou-se tempo cirúrgico total (TCT), tempo de adrenalectomia (TA) e integridade das glândulas após remoção. Foram realizadas 38 adrenalectomias em 19 cadáveres. Independentemente do antímero, o TCT foi significativamente menor nos procedimentos com CO2 do que com liftlaparoscopy (P=0,001). Na comparação das técnicas entre antímeros, o TCT foi significativamente maior no lado esquerdo com liftlaparoscopy do que com CO2 (P = 0,015) e semelhante entre as técnicas no lado direito dos animais (P=0,086). Já na comparação do TA, independente do lado de execução, não foram observadas diferenças entre os métodos (P=0,05). O mesmo foi observado quando o TA foi avaliado separadamente por antímero (P=0,902). Das 38 adrenais avaliadas, 92,1% foram removidas em um único bloco e destas, 32,29% apresentaram lesão superficial na cápsula. Não houve diferença entre grupos para capacidade de remoção em um único bloco (P=0,340) e da integridade da cápsula (P=0,287). A adrenalectomia laparoscópica por elevação da parede abdominal é factível de ser realizada em cadáveres de cães, entretanto, demanda maior tempo cirúrgico quando comparada à técnica convencional. Além disso, a força de tração empregada para elevar a parede abdominal necessita ser avaliada.

Prevalence of reported incidental adrenal findings in chest computerized tomography scans performed during the COVID-19 pandemic in a single center in Northeast Brazil

ABSTRACT Objective: We investigated the prevalence of adrenal incidentalomas (AIs) in a nonselected Brazilian population in chest computed tomography (CT) performed during the COVID-19 pandemic. Materials and methods: This was a retrospective cross-sectional observational study using chest CT reports from a tertiary in- and outpatient radiology clinic from March to September 2020. AIs were defined by changes in the shape, size, or density of the gland initially identified in the released report. Individuals with multiple studies were included, and duplicates were removed. Exams with positive findings were reviewed by a single radiologist. Results: A total of 10,329 chest CTs were reviewed, and after duplicate removal, 8,207 exams were included. The median age was 45 years [IQR 35-59 years], and 4,667 (56.8%) were female. Thirty-eight lesions were identified in 36 patients (prevalence 0.44%). A higher prevalence was observed with age, with 94.4% of the findings in patients aged 40 years and over (RR 9.98 IC 2.39-41.58, p 0.002), but there was no significant difference between the sexes. Seventeen lesions (44.7%) had more than 10 HU, and five lesions (12.1%) were more than 4 cm. Conclusions: The prevalence of AIs in an unselected and unreviewed population in a Brazilian clinic is low. The impact on the health system caused by AIs discovered during the pandemic should be small regarding the need for specialized follow-up.

Frequency of lipid-poor adrenal adenomas in magnetic resonance imaging examinations of the abdomen.

Objective: To estimate the frequency of lipid-poor adenomas (LPAs) in magnetic resonance imaging (MRI) examinations. Materials and Methods: We retrospectively investigated adrenal lesions on MRI examinations performed in a total of 2,014 patients between January 2016 and December 2017. After exclusions, the sample comprised 69 patients with 74 proven adenomas. Two readers (reader 1 and reader 2) evaluated lesion size, laterality, homogeneity, signal drop on out-of-phase (OP) images, and the signal intensity index (SII). An LPA was defined as a lesion with no signal drop on OP images and an SII < 16.5%. For 68 lesions, computed tomography (CT) scans (obtained within one year of the MRI) were also reviewed. Results: Of the 69 patients evaluated, 42 (60.8%) were women and 27 (39.2%) were men. The mean age was 59.2 ± 14.1 years. Among the 74 confirmed adrenal adenomas evaluated, the mean lesion size was 18.5 ± 7.7 mm (range, 7.0-56.0 mm) for reader 1 and 21.0 ± 8.3 mm (range, 7.0-55.0 mm) for reader 2 (p = 0.055). On the basis of the signal drop in OP MRI sequences, both readers identified five (6.8%) of the 74 lesions as being LPAs. When determined on the basis of the SII, that frequency was three (4.0%) for reader 1 and four (5.4%) for reader 2. On CT, 21 (30.8%) of the 68 lesions evaluated were classified as LPAs. Conclusion: The prevalence of LPA was significantly lower on MRI than on CT. That prevalence tends to be even lower when the definition of LPA relies on a quantitative analysis rather than on a qualitative (visual) analysis.

Objetivo: Estimar a frequência de adenomas pobres em lipídios (APLs) em exames de ressonância magnética (RM). Materiais e Métodos: Investigaram-se, retrospectivamente, as lesões adrenais em exames de RM realizados de janeiro de 2016 a dezembro de 2017. Um total de 2.014 pacientes foi submetido a exames abdominais e, após exclusões, 69 pacientes com 74 adenomas foram recuperados. Determinaram-se o tamanho da lesão, a lateralidade, a homogeneidade, a queda do sinal em imagens fora-de-fase (FF) e o índice de intensidade do sinal (IIS). Foram utilizadas as seguintes definições para APLs: sem queda de sinal nas imagens FF e IIS < 16,5%. Para 68 lesões, havia imagens de tomografia computadorizada (TC), com intervalo de até um ano da RM, que também foram analisadas. Resultados: Sessenta e nove pacientes foram incluídos, sendo 42 mulheres (60,8%) e 27 homens (39,2%). A média de idade foi 59,2 ± 14,1 anos. O tamanho médio do adenoma adrenal foi 18,5 ± 7,7 mm para o leitor 1 (7,0-56,0 mm) e 21,0 ± 8,3 mm (7,0-55,0 mm) para o leitor 2 (p = 0,055). A queda de sinal nas imagens FF mostrou que a frequência de APLs para ambos os leitores foi 6,8% (5/74). Para a análise quantitativa, a frequência foi 4,0% (3/74) para o leitor 1 e 5,4% (4/74) para o leitor 2. A frequência de APLs nas imagens de TC foi 21/68 lesões (30,8%). Conclusão: A prevalência de APLs em imagens de RM foi significativamente menor do que em exames de TC. Essa prevalência tende a ser ainda menor quando a definição de APL é baseada na análise quantitativa (IIS < 16,5%), em vez da análise visual.

Frequency of lipid-poor adrenal adenomas in magnetic resonance imaging examinations of the abdomen / Frequência de adenomas adrenais pobres em lipídios em exames de ressonância magnética abdominal

Abstract Objective: To estimate the frequency of lipid-poor adenomas (LPAs) in magnetic resonance imaging (MRI) examinations. Materials and Methods: We retrospectively investigated adrenal lesions on MRI examinations performed in a total of 2,014 patients between January 2016 and December 2017. After exclusions, the sample comprised 69 patients with 74 proven adenomas. Two readers (reader 1 and reader 2) evaluated lesion size, laterality, homogeneity, signal drop on out-of-phase (OP) images, and the signal intensity index (SII). An LPA was defined as a lesion with no signal drop on OP images and an SII < 16.5%. For 68 lesions, computed tomography (CT) scans (obtained within one year of the MRI) were also reviewed. Results: Of the 69 patients evaluated, 42 (60.8%) were women and 27 (39.2%) were men. The mean age was 59.2 ± 14.1 years. Among the 74 confirmed adrenal adenomas evaluated, the mean lesion size was 18.5 ± 7.7 mm (range, 7.0-56.0 mm) for reader 1 and 21.0 ± 8.3 mm (range, 7.0-55.0 mm) for reader 2 (p = 0.055). On the basis of the signal drop in OP MRI sequences, both readers identified five (6.8%) of the 74 lesions as being LPAs. When determined on the basis of the SII, that frequency was three (4.0%) for reader 1 and four (5.4%) for reader 2. On CT, 21 (30.8%) of the 68 lesions evaluated were classified as LPAs. Conclusion: The prevalence of LPA was significantly lower on MRI than on CT. That prevalence tends to be even lower when the definition of LPA relies on a quantitative analysis rather than on a qualitative (visual) analysis.

Resumo Objetivo: Estimar a frequência de adenomas pobres em lipídios (APLs) em exames de ressonância magnética (RM). Materiais e Métodos: Investigaram-se, retrospectivamente, as lesões adrenais em exames de RM realizados de janeiro de 2016 a dezembro de 2017. Um total de 2.014 pacientes foi submetido a exames abdominais e, após exclusões, 69 pacientes com 74 adenomas foram recuperados. Determinaram-se o tamanho da lesão, a lateralidade, a homogeneidade, a queda do sinal em imagens fora-de-fase (FF) e o índice de intensidade do sinal (IIS). Foram utilizadas as seguintes definições para APLs: sem queda de sinal nas imagens FF e IIS < 16,5%. Para 68 lesões, havia imagens de tomografia computadorizada (TC), com intervalo de até um ano da RM, que também foram analisadas. Resultados: Sessenta e nove pacientes foram incluídos, sendo 42 mulheres (60,8%) e 27 homens (39,2%). A média de idade foi 59,2 ± 14,1 anos. O tamanho médio do adenoma adrenal foi 18,5 ± 7,7 mm para o leitor 1 (7,0-56,0 mm) e 21,0 ± 8,3 mm (7,0-55,0 mm) para o leitor 2 (p = 0,055). A queda de sinal nas imagens FF mostrou que a frequência de APLs para ambos os leitores foi 6,8% (5/74). Para a análise quantitativa, a frequência foi 4,0% (3/74) para o leitor 1 e 5,4% (4/74) para o leitor 2. A frequência de APLs nas imagens de TC foi 21/68 lesões (30,8%). Conclusão: A prevalência de APLs em imagens de RM foi significativamente menor do que em exames de TC. Essa prevalência tende a ser ainda menor quando a definição de APL é baseada na análise quantitativa (IIS < 16,5%), em vez da análise visual.

Analysis of adrenalectomy for the treatment of adrenal diseases performed by the Public Health Service in São Paulo between 2008 and 2019 / Análise da adrenalectomia para tratamento de doenças adrenais realizadas pelo Serviço Público de Saúde de São Paulo entre 2008 e 2019

ABSTRACT Introduction: treating benign (hormonally active or nonfunctional) and malignant adrenal cancer includes adrenalectomy. The expertise of surgeons and surgery performed by high-volume surgeons were associated with fewer complications and lower cost. We aimed to describe and compare the number of surgeries, mortality rate, and length of hospital stay for adrenalectomies performed between 2008 and 2019 in the public health system of São Paulo. Methods: this was an ecological study. The data were collected using the TabNet Platform of the Unified Health System Department of Informatics. Outcomes analyzed included the number of surgeries performed, mortality rate during hospital stay, and length of hospital stay. Public hospitals in Sao Paulo were divided into three subgroups according to the surgical volume of adrenalectomies performed as well as hospitals with and without a residency program in Urology, and the results were compared among them. Results: a total of 943 adrenalectomies were performed in Sao Paulo between 2008 and 2019. Mortality rates during hospital stay according to hospital surgical volume were no reported deaths in low-volume, 0.015% in intermediate-volume, and 0.004% in high-volume hospitals. The average length of the ICU stay was 1.03 days in low-volume, 2.8 in intermediate-volume, and 1.12 in high-volume hospitals (analysis between intermediate and high volume centers with statistical significance, p=0.016). Conclusions: despite no statistically significant differences among the groups analyzed, mortality rates were very low in all groups. ICU stay was shorter in high-volume centers than in intermediate-volume centers.

RESUMO Introdução: o tratamento do câncer de adrenal benigno (hormonalmente ativo ou não funcional) e maligno inclui a adrenalectomia. A experiência dos cirurgiões e a cirurgia realizada por cirurgiões de alto volume foram associadas a menos complicações e menor custo. O objetivo do estudo foi descrever e comparar o número de cirurgias, a taxa de mortalidade e o tempo de internação para adrenalectomias realizadas entre 2008 e 2019 na rede pública de saúde de São Paulo. Métodos: trata-se de um estudo ecológico. Os dados foram coletados da Plataforma TabNet do Departamento de Informática do Sistema Único de Saúde. Os hospitais foram divididos em três subgrupos de acordo com o volume cirúrgico e hospitais com e sem programa de residência médica em Urologia. Os resultados foram comparados entre os grupos. Resultados: no período estudado, 943 adrenalectomias foram realizadas em São Paulo. As taxas de mortalidade durante a internação de acordo com o volume cirúrgico hospitalar foram: não foram relatados óbitos em hospitais de baixo volume; 0,015% em hospitais de volume intermediário e 0,004% em alto volume. O tempo médio de permanência na UTI foi de 1,03 dias nos hospitais de baixo volume; 2,8 nos de médio volume e 1,12 nos de alto volume (análise entre centros de médio e alto volume com significância estatística, p=0,016). Conclusão: as taxas de mortalidade foram muito baixas em todos os grupos. A permanência na UTI foi menor em centros de alto volume do que em centros de volume intermediário.

Solitary fibrous tumor of the left adrenal gland associated with Doege-Potter syndrome. Case report.

We present the case of a 71-year-old man with a history of type 2 diabetes mellitus manifesting abdominal pain, weight loss, dyspnea on small efforts, muscle weakness, and left subcostal swelling. Associated with this, he developed frequent episodes of syncope, diaphoresis, and night sweats, during which blood glucose levels below 50 mg/dL and improvement were documented after the administration of hypercaloric beverages or intravenous dextrose. Abdominal computed tomography revealed the presence of a tumor of approximately 20 cm dependent on the left adrenal gland. Histopathological diagnosis of a solitary retroperitoneal fibrous tumor was obtained, confirmed by immunohistochemistry.

Se presenta el caso de un varón de 71 años con antecedente de diabetes mellitus tipo 2 que manifiesta dolor abdominal, pérdida de peso, disnea de pequeños esfuerzos, debilidad muscular y aumento de volumen subcostal izquierdo. Asociado a esto desarrolló episodios frecuentes de síncope, diaforesis y sudoraciones nocturnas, durante los cuales se documentaron cifras de glucemia < 50 mg/dl y mejoría tras la administración de bebidas hipercalóricas o dextrosa intravenosa. La tomografía computarizada abdominal reveló la presencia de una tumoración de aproximadamente 20 cm dependiente de la glándula suprarrenal izquierda. Se obtuvo diagnóstico histopatológico de tumor fibroso solitario retroperitoneal confirmado por inmunohistoquímica.

Impacto cardiovascular, conducta diagnóstica y terapéutica del feocromocitoma como causa de hipertensión arterial / Cardiovascular impact, diagnostic and therapeutic management of pheochromocytoma as a cause of arterial hypertension

INTRODUCCIÓN. Los feocromocitomas son tumores que provienen de las células neuroendócrinas de la médula adrenal y producen alta secreción de catecolaminas. Generan complicaciones cardiovasculares graves que suelen asociarse con crisis hipertensivas. Es importante valorar el impacto cardiovascular de esta entidad. OBJETIVO. Realizar una revisión exhaustiva de las diversas manifestaciones de los feocromocitomas como causa de hipertensión arterial, su impacto cardiovascular, conducta diagnóstica y terapéutica. MATERIALES Y MÉTODOS. Revisión bibliográfica y análisis de 141 artículos científicos que incluyeron temas sobre el impacto cardiovascular, conducta diagnóstica y terapéutica del feocromocitoma como causa de hipertensión arterial. Se usó bases de datos: Medline, Embase, Scopus, Pubmed, Google Académico. Criterios de búsqueda en DECS, MeSH: "pheochromocytoma OR hypertension arterial AND cardiomyopathy", en inglés- español. Fueron seleccionados: 13 publicaciones de texto completo, 10 artículos retrospectivos, 2 guías de práctica clínica y 1 revisión. Se excluyeron 128 artículos científicos. RESULTADOS. Se realizó una revisión de las manifestaciones clínicas de los feocromocitomas como causa de hipertensión arterial y el impacto cardiovascular se relacionó con la producción de catecolaminas. Para el diagnóstico, la sensibilidad de la resonancia magnética es del 93-100%; la especificidad de resonancia magnética o tomografía computarizada en combinación con gammagrafía con metayodobencilguanidina con 123I es cercana al 100%. La resección del feocromocitoma tiene potencial curativo. CONCLUSIÓN. Los feocromocitomas presentan variabilidad clínica, se asocian a complicaciones cardiovasculares y cerebrovasculares graves por producción de catecolaminas. El diagnóstico oportuno y eficaz debe realizarse mediante resonancia magnética y gammagrafía en caso de alta sospecha clínica. El tratamiento quirúrgico es de elección.

INTRODUCTION. Pheochromocytomas are tumors arising from the neuroendocrine cells of the adrenal medulla and produce high secretion of catecholamines. They generate severe cardiovascular complications that are often associated with hypertensive crises. It is important to assess the cardiovascular impact of this entity. OBJECTIVE. To perform an exhaustive review of the various manifestations of pheochromocytomas as a cause of arterial hypertension, their cardiovascular impact, diagnostic and therapeutic conduct. MATERIALS AND METHODS. Bibliographic review and analysis of 141 scientific articles that included topics on the cardiovascular impact, diagnostic and therapeutic behavior of pheochromocytoma as a cause of arterial hypertension. The following databases were used: Medline, Embase, Scopus, Pubmed, Google Scholar. Search criteria in DECS, MeSH: "pheochromocytoma OR hypertension arterial AND cardiomyopathy", in English-Spanish. The following were selected: 13 full-text publications, 10 retrospective articles, 2 clinical practice guidelines, and 1 review. A total of 128 scientific articles were excluded. RESULTS. A review of the clinical manifestations of pheochromocytoma as a cause of arterial hypertension was performed and the cardiovascular impact was related to catecholamine production. For diagnosis, the sensitivity of MRI is 93-100%; the specificity of MRI or computed tomography in combination with 123I-methiodobenzylguanidine scintigraphy is close to 100%. Resection of pheochromocytoma has curative potential. CONCLUSION. Pheochromocytomas present clinical variability, are associated with severe cardiovascular and cerebrovascular complications due to catecholamine production. Timely and effective diagnosis should be made by MRI and scintigraphy in case of high clinical suspicion. Surgical treatment is the treatment of choice.