Adrenal Surgery in the Era of Multidisciplinary Endocrine Tumor Boards

Abstract

Work up of adrenal masses includes assessment of endocrine activity and malignancy risk. There is no indication for surgical removal of nonfunctional adrenal adenomas, according to the guidelines. In the present study, we aimed at evaluating the impact of a university endocrine tumor board on the quality of the indications for adrenal surgery at our institution. One hundred consecutive patients receiving primary adrenal surgery at the University Hospital of Cologne, Germany were included. Their demographics, clinic-pathologic characteristics, treatment and outcome were analyzed. In 55 (55%) cases, indication for surgery consisted in functional benign tumors, including Conn, Cushing adenomas and pheochromocytomas. Forty (40%) tumors were referred to surgery for malignancy suspicion and 5 (5%) myelolipomas were removed due to their size. Eighty-nine percent of surgeries were performed as minimally invasive procedures. Overall morbidity included two (2%) self-limiting pancreatic fistulas after left laparoscopic adrenalectomy for pheochromocytoma. All functional tumors were confirmed benign by final histology. Only 33 (82.5%) of 40 suspicious cases turned out to be malignant. Consequently, nonfunctional benign adenomas were “unnecessarily” removed in only 7 (7%) patients, with 6 (85.7%) of them having a history of extra-adrenal cancer and all of them fulfilling criteria for surgery, according to the international guidelines. In conclusion, the endocrine tumor board provided an excellent adherence to the guidelines with most surgeries being performed either for functional or malignant tumors. In nonfunctional tumors with history of extra adrenal cancer, CT guided biopsy might be considered for obviating surgery.

The Impact of the COVID Pandemic on Adrenal Surgery at an Academic Endocrine Surgery Unit

“…All adrenal tumors received radiologic workup (using either enhanced or non-enhanced CT, MRI, or PET CT), at least minimal endocrinologic diagnostic including aldosterone/renin ratio, serum metanephrine and normetanephrine levels and a dexamethasone suppression test, as described previously [8]. In case of positive aldosterone/renin ratio, suggestive of Conn Adenoma, the next step consists of saline load test and selective adrenal vein sampling for patients > 35 years at our institution [8]. Our internal algorithm is based on the guidelines for the management of adrenal incidentaloma of the European Society of Endocrinology in collaboration with the European Network for the Study of Adrenal Tumors [9].…”

“…All adrenal pathologies are discussed in our endocrine board including endocrinology, nuclear medicine, surgery and pathology. All indications to surgery are posed in interdisciplinary consensus, as described previously [8]. Additionally, a pheochromocytoma task force including endocrinology, nephrology, surgery and anesthesiology discusses whether to administer preoperative alpha blockade and if postoperative intensive care unit (ICU) monitoring is required.…”

“…Open adrenalectomy is performed only rarely and mostly due to adrenal carcinoma suspicion. Laparoscopic access is chosen at our institution for masses suspicious of malignancy but without signs of extra-adrenal invasion, due to the lower risk of capsular disruption given by the larger space in trans peritoneal access [8]. Retroperitoneoscopic access is preferred for functional benign tumors and in patients with previous abdominal surgery, where adhesions are expected.…”

“…Retroperitoneoscopic access is preferred for functional benign tumors and in patients with previous abdominal surgery, where adhesions are expected. All patients were seen regularly one week postoperatively for wound control in the surgical department and in the endocrinologic department for further follow up, especially in case of corticosteroid substitution, as described previously [8].…”