Adrenal nodules in patients with Cushing's disease: prevalence, clinical significance and follow-up.

UNLABELLED: Adrenal glands in Cushing's disease (CD) range from normal to showing diffuse enlargement in most cases. The finding of nodular lesions has been reported, but information about prevalence and evolution is described in few reports. AIM: To investigate the prevalence of nodular adrenal glands in patients with CD and assess its evolution after disease remission. SUBJECTS AND METHODS: We assessed 41 CD patients' abdominal computed tomography (CT) scans obtained during the active phase of the disease and evaluated the dynamics of ACTH and cortisol secretion. CT was repeated after disease remission in patients with adrenal nodules. RESULTS: Fifteen of 41 patients had nodular and the remaining 26 had normal or enlarged adrenal glands. Patients with nodules were older (45.1 ± 8.8 vs 36.9 ± 12.7 yr; p=0.03) and had longer-standing disease (57.3 ± 56.9 vs 32.9 ± 29.1 months; p=0.05) than patients with normal/enlarged adrenal glands. ACTH (45.4 ± 21.3 vs 70.5 ± 39.1 pg/ml; p=0.04) and urinary free cortisol levels (606.1 ± 512.3 vs 301.0 ± 224.7 µg/day, p=0.01) were significantly lower in patients with adrenal nodules while there were no differences between the groups in terms of dynamic tests results. Post-operative follow-up showed regression or shrinkage of the nodules in 8 out of 10 patients in disease remission. CONCLUSIONS: We found that adrenal nodular glands are a frequent finding in CD in particular in older patients and in those with a longerstanding disease. Nevertheless, a high percentage of nodules regression or shrinking was evidenced in our series after disease remission.

Usefulness of CT scan, MRI and radiocholesterol scintigraphy for adrenal imaging in Cushing's syndrome.

The aim of this study was to evaluate the sensitivity and accuracy of computed tomography (CT) scanning, 75Se-selenomethyl-norcholesterol scintigraphy (SNS) and magnetic resonance imaging (MRI) in patients with Cushing's syndrome (CS) undergoing adrenalectomy. A series of 67 patients with CS due to benign adrenal disease was reviewed. There were 11 (16.4%) men and 56 (83.6%) women, with an overall median age of 44 years (range 19-69 years). Prior to surgery all patients underwent both CT and SNS, and 58 (86.6%) underwent adrenal MRI. Thirty-five (52.2%) of the patients (group A) had histologically confirmed unilateral adrenal involvement (33 patients with a solitary adrenocortical adenoma, and two with unilateral nodular cortical hyperplasia), while 32 (47.8%) of the patients (group B) had CS caused by bilateral adrenal involvement, including two patients with multinodular adrenal hyperplasia. The sensitivity, specificity and accuracy of adrenal imaging in group A were 97.1%, 100% and 98.5% for SNS, 94.3%, 68.7% (P<0.05, chi2 test) and 82.1% for CT scan, and 92.3%, 60.0% (P<0.05) and 64.3% (P<0.05) for MRI, respectively. In group B the sensitivity, specificity and accuracy were 100%, 97.2% and 98.5% for SNS, 64.5% (P<0.05), 97.2% and 82.1% for CT scan, and 60.0% (P<0.05), 92.3% and 35.7% (P<0.05) for MRI, respectively. In conclusion, SNS represents the most sensitive and specific adrenal imaging study and should be used in all patients with confirmed biochemical diagnosis of CS undergoing adrenalectomy. The sensitivity and specificity of CT scan and MRI are similar, but the latter shows a lower accuracy, especially in patients with bilateral adrenal involvement.

Transcatheter arterial chemoembolization for hepatocellular carcinoma in patients with Child's grade A or B cirrhosis: a multivariate analysis of prognostic factors.

We evaluated factors affecting long-term survival after transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) complicating cirrhosis. One hundred eighty-two patients with Child's class A or B cirrhosis and an HCC, not amenable to surgery or percutaneous ethanol injection, underwent 346 TACEs (mean 1.9) with epirubicin, iodized oil, and gelatin sponge. Many prognostic factors were subjected to univariate analysis and thereafter, when significant, to the Cox's hazard proportional model. Finally, the significant indices in the Cox's model were used to estimate the accuracy of the probability of death with computation of the area under the receiving operative characteristic (ROC) curve. The cumulative survival rates at 1, 2, 3, and 5 years were 0.83, 0.52, 0.40, and 0.16, respectively. According to Cox's model, the factors associated with significantly worse survival were the presence of ascites (p = 0.0027), elevated bilirubin levels (p = 0.0163), elevated alpha-fetoprotein (alphaFP) values (p = 0.0067), a tumor greater than 5 cm in diameter (p = 0.0001), and the absence of a tumor capsule-like rim (p = 0.0278). According to these parameters, the accuracy of the probability of death estimated with ROC analysis was 0.63. Minor and major complications occurred in 82 patients (45%) and caused death in 2 patients. Long-term prognosis after TACE for HCCs in patients with Child's class A or B cirrhosis depends on the presence of ascites, the bilirubin level, the alphaFP value, the diameter of the tumor, and the presence of a tumor capsule-like rim. However, when considered altogether, these variables are poor predictors to evaluate survival, and other factors should be investigated to identify subjects more responsive to TACE. Complications occur in a high percentage of patients, but they do not affect long-term prognosis.

[The preoperative chemoembolization of hepatocarcinoma due to cirrhosis]. / La chemioembolizzazione preoperatoria dell'epatocarcinoma su cirrosi.

PURPOSE: To investigate clinical value and tumor response of preoperative transcatheter arterial chemoembolization for hepatocellular carcinoma (HCC) secondary to cirrhosis. MATERIALS AND METHODS: The clinical, radiologic and histologic findings were reviewed relative to 13 cirrhotic patients operated on for HCC after chemoembolization with an emulsion of Lipiodol UF and epirubucin; additional gel-foam embolization was performed in 12 cases. RESULTS: The mean survival was 24 months. Three patients died within 1 month after surgery; 2 other patients died 10 and 32 months after surgery, respectively. The 2-year recurrence rate was 40%. Tumor size, the grade of iodized oil retention and the embolization technique affected primary tumor necrosis ratio: most of satellite nodules and capsular invasions were persistently viable at histology. CONCLUSIONS: Preoperative chemoembolization neither facilitates, nor contraindicates, HCC surgery. Nevertheless, chemoembolization should always be performed before surgery first to stage the patients with Lipiodol CT and second to administer the first palliation whenever the patient is ineligible for surgery.