Surgical approach to adrenal masses

BÜLENT GÜNLÜSOY,Sedat ÇİÇEK,Atilla TİLKİ,Nihat NERGİZ,Süleyman MİNARECİ,A. Rıza AYDER

Abstract

Introduction: Surrenal masses can be benign or malign. Development and wide spread usage of radiologic imaging techniques allow the diagnosis of smaller, localized adrenocortical malignancies which is more amenable to curative therapy, in this study, we retrospectively evaluated surgical approaches and pathologic results of 22 adrenal masses. Materials and Methods: Between October 1992 and February 2002, 22 patients underwent surgical exploration for adrenal masses. There were 12 women and 10 men with a mean age 61 years (range 48 to 73 years). Median follow-up from the fırst diagnosis of the adrenal mass was 42 months (range between 4-58 months). Patients underwent ultrasonography and abdominal computerized tomography. Blood levels of adrenal hormones were measured and 24 hour urines were collected for catecholamine excretion. 6 (18%) benign and 3 (16%) malign tumors were hormon-active. Of the 22 adrenal tumors, 8 were on the right side, 11 were on the left side and 3 were bilateral. Diameter of tumors was measured by ultrasonography or computerized tomography. Follow-up in the postoperative period consisted of abdominal computerized tomography every 3 months after surgery and endocrinologic test of adrenal metabolites in hormon-active tumors. Results: There were no mortalities related to surgical procedures. Modified posterior approach was our surgical choice for adrenal surgery. The incision was extended through anterior in 2 adrenal tumors which is invasive abdominal organs. 2 patients had transient adrenal insufficiency after the operation and supportive therapy was done. 2 metastatic adrenal masses can not be surgically excised and only biopsies were taken. Of the four patients with primary adrenal carcinoma, one mass was excised partially in pathologic examination, 6 (27%) patients had adenoma, 4 (18%) had adrenal hyperplasia, 4 (18%) had adrenal carcinoma, 2 (9%) surrenal cyst, 2 (9%) pheochromocytoma, l (5%) myolipoma, l (5%) ganglioneuroblastoma and 2 (9%) metastatic adrenal carcinoma. Mean tümör volume was 12 cm (range 3.7 to 19 cm). Metastatic carcinomas were highly aggressive in post-operative period and 2 patients died in 5 months. One patient with ganglioneuroblastoma and one patient with primary adrenal carcinoma died in 8 months. There were no residuel mass on metastasis postoperatively in 2 patients with local invasive adrenal carcinoma after 4 years. Conclusion: Benign adrenal masses can easily be diagnosed and successfully excised. Hormone levels should be determined in symptomatic and asymptomatic patients with adrenal masses. Early stage malign tumors are suitable for curative resection with additional treatment. Modified posterior flank incision is appropriate for non-invasive and unilateral tumors.

Özet

Surrenal kitleleri benin veya malin olabilir. Radyolojik görüntüleme yöntemlerinin gelişimi ve yaygın kullanımı sayesinde küratif tedavisi mümkün küçük ve lokalize adrenokortikal malinitelerin tanısı konabilmektedir. Bu çalışmada kliniğimizde surrenal kitlesi ön tanısıyla opere edilen 22 olguda cerrahi yaklaşımlarımızı ve patoloji sonuçlarını değerlendirildik. Ekim 1992-Şubat 2002 tarihleri arasında 22 hastaya (10 erkek, 12 kadın) surrenal kitle tanısıyla cerrahi eksplorasyon yapıldı. Hastaların yaş ortalaması 61 (48-73) idi. İlk tanıdan itibaren ortalama izlem süresi 42 aydır (4-58 ay). Hormonal incelemede surrenal hormonlarının kan düzeyleri ve idrar metabolitleri ölçüldü. Benin kitlelerden 6'sı hormon aktif iken malin tümörlerinin 3'ü hormon aktif idi. 8 hastada sağ sürrenalde, 11 hastada sol sürrenalde ve 3 hastada çift taraflı surrenal kitle varlığı mevcuttu. Tümör çapları ultrasonografı ve tomografi ile ölçüldü. Operasyonlar ile ilgili mortalite saptanmadı. Cerrahi yaklaşım olarak modifıye posteriyor insizyonu tercih ettik. Metastatik 2 tümör inop kabul edildi ve biyopsi alındı. Operasyon sonrası 2 hastada geçici surrenal yetmezliği gelişti ve destek tedavisi uygulandı. Patolojik incelemede 6 olguda (%27) adenom, 4 olguda (%18) adrenal hiperplazi, 4 olguda (%18) surrenal karsinom, 2 olguda (%9) surrenal kist, 2 olguda (%9) feokromositoma, l olguda (%5) miyolipoma, l olguda (%5) ganglionöroblastoma ve 2 olguda (% 9) metastatik surrenal karsinom saptandı. Benin sürrenal kitlelerin tanıları kolaydır ve cerrahi olarak başarı ile çıkarılabilir. Hormon ölçümleri semptomatik ve asemprometik tüm hastalarda bakılmalıdır. Erken dönemde saptanan malin tümörlerde ek tedavilerle birlikte kür sağlanabilir. Non-invaziv ve tek taraflı sürrenal kitlelerinde modifiye posteriyor insizyon uygun bir cerrahi yaklaşımdır.