FATİH URUÇ, Aytaç ŞAHİN, BEKİR ARAS, Ahmet ÜRKMEZ, Mithat KIVRAK, Timuçin AYDIN, Seda SANCAK, Ayhan VERİT

Cerrahi tedavi uyguladığımız mini-insidentaloma serimiz

Amaç: Adrenal insidentalomalar adrenal bezlerde 1 cm’den büyük lezyonlar olarak tanımlanmaktadır ve insidansı % 1.4-8.7 ort. % been defined as adrenal lesions less than 1 cm in 2.3’tür. 1cm’den küçük adrenal kitleler genelliksize with an incidence ranging between 1.4, and le non-fonksiyonedir. 6 cm’den büyük adrenal 8.7 % median 2.3%. Adrenal masses less than kitleler ise % 40 olasılıkla fonsiyone kitlelerdir. 1 cm are generally non-functional, while tho4cm’den küçük adrenal kitlelerin malign olma se larger than 6 cm in diameter are functional potansiyelleri %2 iken bu oran 4-6 cm arasi adwith a probability of 40 percent. Adrenal masses renal kitlelerde % 6 ve 6 cm den büyük kitlelerde ise %25’e çıkmaktadır. Ayrıca 4 cm üzeri fonksiyonel olmayan adrenal kitleler cerrahi 4-6 cm or greater than 6 cm have malignancy için adayken, küçük miyelolipomlar, benign potentials of 6 %, and 25 %, respectively. Besikistler ve fonksiyonel olmayan adenomlar des, non-functional adrenal masses larger than 4 semptomatik olmadıkça cerrahi gerektirmeyecm are candidates for surgery, however for small bilirler. Bu çalışmada klinik pratiğimizde rastladığımız adrenal kitlelere yaklaşım ve cerrahi adenomas surgical treatment may not be requtedavilerinin literatür eşliğinde gözden geçirilired unless they become symptomatic.In this mesi amaçlanmıştır.Gereç ve Yöntemler: Ocak 2010-Ocak review approach to, and surgical treatment of adrenal masses which we encounter in our cli2015 yılları arasında üroloji ve genel cerrahi kliniklerince adrenal kitle nedeniyle takip ettiğimiz ve cerrahi tedavi uyguladığımız hastalar retrospektif olarak taranmış ve 14 hasta followed up, and treated surgically between Jaincelemeye alınmıştır. Hastalar Ultrasonografi nuary 2010, and January 2015 in our clinics of USG, bilgisayarlı tomografi BT veya Manyetik urology, and general surgery with the indication Rezonans MR görüntüleme yöntemleri kullaof adrenal mass, were retrospectively screened, nılarak görüntülendi. Hastaların biyokimyasal kan tetkiklerinde dehidroepiandrosteron The patients underwent ultrasonographic US, DHEA, kortizol, metanefrin, normetanefrin, computed tomographic CT and magnetic retotal testosteron, tiroid stimulan hormon TSH, vanil mandelik asit VMA, aldosteron ve renin cal blood analyses of dehydroepiandrosterone bakıldı. Hastalarımızdan 3’ü fonksiyone , 11’ i DHEA, cortisol, metanephrine, normetanephise non-fonksiyone adrenal kitle olarak değerlendirildi.Bulgular: Çalışmaya 4 erkek 10 kadın dosterone, and renin were performed. Adrenal toplamda 14 hasta dahil edilmiştir. Hastaların yaş ortalaması 54.7 33-74 yaş arası. Ortalama kitle boyutları 8.8cm 5,5 ila 23 cm arası. Bunların 5’ine açık cerrahi eksizyon 9’una ise laparoskopik cerrahi eksizyon uygulanmıştır. Hastaların patoloji sonuçlarına göre 2’si malign karakterde 12’si benign karakter gösteren lezyon olarak raporlandı. Sonuç: Adrenal bezler anatomik olarak küçük organlar olmasına karşın fonksiyonları hayati önem arz etmektedir. Bu yüzdendir ki adrenal kitlelere yaklaşım ve onların tedavi yönetimi cerrahi tedavi öncesi mutlaka endokrinolojik olarak değerlendirilmeli ve ameliyat öncesi gerekli endokrin hazırlıklar tamamlanmalıdır. Özellikle hormon aktif olguların endokrinopati açısından pre-operatif, peroperatif ve post-operatif hazırlanması çok önemlidir. Cerrahi başarı multidisipliner çalışma ile doğru orantılıdır

Anahtar Kelimeler:

İnsidentaloma, cerrahi tedavi, multidisip

Our mini-incidentaloma series whom we applied surgical treatment

Objective: Adrenal incidentolamas have been defined as adrenal lesions less than 1 cm in size with an incidence ranging between 1.4, and 8.7 % median 2.3%. Adrenal masses less than 1 cm are generally non-functional, while those larger than 6 cm in diameter are functional with a probability of 40 percent. Adrenal masses smaller than 4 cm in diameter has a malignancy potential of 2 percent. While those measuring 4-6 cm or greater than 6 cm have malignancy potentials of 6 %, and 25 %, respectively. Besides, non-functional adrenal masses larger than 4 cm are candidates for surgery, however for small myelipomas, benign cysts, and non-functional adenomas surgical treatment may not be required unless they become symptomatic.In this study, in the light of the literature, we aimed to review approach to, and surgical treatment of adrenal masses which we encounter in our clinical practice. Material and Methods: Patients whom we followed up, and treated surgically between January 2010, and January 2015 in our clinics of urology, and general surgery with the indication of adrenal mass, were retrospectively screened, and 14 patients were included in our analysis. The patients underwent ultrasonographic US, computed tomographic CT and magnetic resonance imaging MRI techniques. Biochemical blood analyses of dehydroepiandrosterone DHEA, cortisol, metanephrine, normetanephrine, total testosterone, thyroid stimulating hormone TSH, vanillyl mandelic acid VMA, aldosterone, and renin were performed. Adrenal masses of our patients were evaluated as functional in 3, and nonfunctional in 11 cases. Results: A total of 14 patients 4 male, and 10 female were included in the study. Mean age of the patients was 54.7 years range, 33-74 yrs. Mean diameter of the adrenal masses was 8.8 cm range, 5.5 - 23 cm. These patients underwent open surgical excision n=5 or laparoscopic surgical excision n=9. Histopathology of the adrenal masses was reported as malign n=2 or benign n=12 lesions. Conclusion: Adrenal glands are anatomically small in size, however they possess critically important vital functions. Therefore, approach to adrenal masses, and their treatment should be evaluated preoperatively from endocrinologic perspective, and necessary endocrinologic preparations should be completed before the surgery. Pre-, peri-, and post-operative elaboration of especially hormone-active cases carries utmost importance. Surgical success is directly proportional to multidisciplinary collaboration.

Keywords:

İncidentolama, surgical treatment, multidiscipli,

PDF

___

Young WF Jr. Clinical practice. The incidentally discovered adrenal mass. N Engl J Med 2007; 356:601.
Kuşkonmaz ŞM, Tütüncü NB. Adrenal Incidentaloma. Turkiye Klinikleri J Endocrin-Special Topics 2013; 6:56-62
Bansal P, Gupta A, Mongha R, Kundu AK. Virilizing adre- nal carcinoma with inferior cava thrombus. Indian J Can- cer 2009;46:247-9.
Hevia Suarez M, Abascal Junquera JM, Boix P, et al. Ma- nagement of adrenal mass: What urologists should know. Actas Urol Esp 2010; 34:586-91 .
Herrera MF, Grant CS, van Heerden JA, Sheedy PF, Ilstrup DM. Incidentally discovered adrenal tumors: an institutio- nal perspective. Surgery 1991; 110:1014.
Bovio S, Cataldi A, Reimondo G, et al. Prevalence of ad- renal incidentaloma in a contemporary computerized to- mography series. J Endocrinol Invest 2006; 29:298-302.
Barzon L, Scaroni C, Sonino N, et al. Incidentally discove- red adrenal tumors: endocrine and scintigraphic correla- tes. J Clin Endocrinol Metab 1998; 83:55-62.
Zeiger MA, Thompson GB, Duh QY, et al. The American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons medical guidelines for the management of adrenal incidentalomas. Endocr Pract 2009;15:1-20
De Leon Morales E, Bielsa Gali O, Aranga Toro O, Alonso Gracia N, Canis Sanchez D, Adrenal surgical pathology. Report of our cases and bibliographic review. Arch Esp Urol 2003;56,8:875-83.
Barzon L, Boscaro M. Diagnosis and management of adre- nal incidentalomas. J Urol 2000; 163:398-407.
Moreira SG Jr, Pow-Sang JM. Evaluation and management of adrenal masses. Cancer Control 2002; 9:326-34.
Kandıralı E, Erdemir F, Korgalı E, Atılgan D, Esen T, Tunç M. Ürolojinin göz ardı ettiği cerrahi: böbrek üstü bezi cer- rahisi; İstanbul Tıp Fakültesi Deneyimi. Türk Üroloji Der- gisi 2004; 30:290-6.
Prager G, Heinz-Peer G, Passler C, et al. Surgical strategy in adrenal masses. Eur J Radiol 2002; 41:70-7.
Brix D, Allolio B, Fenske W, et al. Laparoscopic Versus Open Adrenalectomy for Adrenocortical Carcinoma: Sur- gical and Oncologic Outcome in 152 patients. Eur Urol 2010; 58:609-15.
Hallfeldt KK, Mussack T, Trupka A, Hohenbleicher F, Schmidbauer S. Laparoscopic lateral adrenalectomy versus open posterior adrenalectomy for the treatment of benign adrenal tumors. Surg Endosc 2003; 17:264-7.
Higashihara E, Baba S, Nakagawa K, et al. Learning curve and conversion to open surgery in cases of laparoscopic adrenalectomy and nephrectomy. J Urol 1998; 159:650-3.
Darracot Vuaghan E, Blumenfeld JD, DelPizzo J, Schich- man SJ, Sosa RE. Las Glandulas suprarenales. En:Campbell :Urology/Walsh Patrick 2004:3849-1916.
Mitchell IC, Nwariaku FE. Adrenal masses in the cancer patient: surveillance or excision. Oncologist 2007;12:168– 174.
Muro Toledo GE, Losada Guerra JL, Martin Perez A, Pe- rez Martin IR. Giant adrenal carcinoma. Case report. Arch Esp Urol 2009; 62:134-6.
Agrons GA, Lonergan GJ, Dickey GE, Perez-Monte JE. Ad- renocortical neoplasms in children: Radiologic-pathologic correlation. Radiographics 1999; 19:989-1008.
Gaujoux S, Al-Ahmadie H, Allen PJ, et al. Resection of ad- renocortical carcinoma liver metastasis: is it justified? Ann Surg Oncol 2012; 19:2643-51.
Kemp C, Ripley R, Mathur A, et al. Pulmonary Resecti- on for Metastatic Adrenocortical Carcinoma: The na- tional cancer Institute Experience. Ann Thorac Surg 2011;92:1195-200.
Dunnick NR, Korobkin M, Francis I. Adrenal radiology: distinguishing benign from malignant adrenal masses. AJR Am J Roentgenol 1996; 167:861-7.
Grogan RH, Mitmaker E, Vriens MR, et al. Adrenal in- cidentaloma: does an adequate workup rule out surpri- ses? Surgery 2010;148:392–7.
Mazzaglia PJ, Vezeridis MP. Laparoscopic adrenalectomy: balancing the operative indications with the technical ad- vances. J Surg Oncol 2010; 101:739–44.
Sturgeon C, Shen WT, Clark OH, Duh QY, Kebebew E. Risk assesment in 457 adrenal cortical carcinomas: how much does tumor size predict the likelihood of malig- nancy? J Am Coll Surg 2006; 202:423–30.
Peterffy A, Dezso B, Adler I, Arkossy P, Szerafin T. Success- ful surgical removal of adrenocortical carcinoma growing into the inferior vena cava and the right atrium. Magy Seb 2008; 61:38-41.
Arnaldi G, Masini AM, Giacchetti G, Taccaliti A, Faloia E, Mantero F. Adrenal incidentaloma. Braz J Med Biol Res 2000; 33:1177-89.
Campbell Urology10th edition. Pathophysiology, Eva- luation and Medical Management of Adrenal Disorders 2012:1685-1736.
Godin K, Bang N, Tolkach Y. Case report: Heterotopic int- rarenally located adrenocortical oncocytoma. F1000Res 2014;3:73.
Stimac G, Katusic J, Sucic M, Ledinsky M, Kruslin B, Trnski D. A giant hemorrhagic adrenal pseudocyst: case report. Med Princ Pract 2008; 17:419-21.