Tumour and cyst of adrenal gland

Incidentaloma of the adrenal gland (tumour found by chance) is a tumour found out during USI investigation. MRT and CT investigations were done when there were no complaints and clinical presentation of the disease of the adrenal gland. These kinds of tumours are detected approximately in 4% of patients, and bilateral lesion is in 15% of cases. Found out neoplasm can be hormonally-non-active and actively generating various hormones, it can be in different zones of the adrenal gland or have non-specific belonging to some organ, can be both malignant and benign.

Diagnostics of tumour of the adrenal gland

The most interesting question for surgeons is a statistic probability of different nosologic forms ( cortisol and aldosterone-producing adenomas, pheochromocytoma, adrenocortical cancer, metastasis into the adrenal gland in case of cancer of it) in case of incidentalomas (finding out tumours of the adrenal gland). The presence of probability is very important from the view-point of the most urgent problems: whether it can become malignant and hormonal activity of tumours.

In case of increased generation of sexual hormones clinical manifestations are obvious, and investigation of the adrenal gland is done properly. It is necessary to investigate the level of cortisol, aldosterone and catecholamines. Fraction determination of metanephrines (separate determination of metanephrine and normetanephrine, if there are indications-then methoxythyramine) in urine or plasma has the best diagnostic sensibility relatively to the initial (i.e. tumour amount) amount of catecholamines, and is recommended as the first diagnostic test in case, if they suspect pheochromocytoma.

Determination of the fact, whether tumour is malignant or not, is also a responsible task for a surgeon when he chooses the technique of operation for tumour of the adrenal gland. The adrenocortical cancer can be found out in 4.2% of patients with incidentalomas.To determine, whether tumour is malignant or not, traditionally they have used 2 parameters: the size of tumour and the speed of its growth. In case, if the size of tumour is more than 4 cm, 25% of them are malignant. The symptom of tumour growth can be evaluated as a diagnostic factor: the fast speed is typical for the cancer of the cortex of the adrenal gland. In scientific literature the case is described when tumour size has been increased twice within several months. The size of tumour has been increased from 3 cm up to 10 cm within a year according to some description. It has been mentioned in literature that during the first CT they have found no tumour, but in a year during the repeated CT the tumour of the adrenal gland has become 12 cm. Minimum growth is typical for benign tumours-several mm per year. The speed of growth of pheochromocytoma is 0.5-1 cm per year, the speed of growth of metastatic carcinoma is variable, it depends on the morphological type of the primary tumour.

Treatment tactics in case of tumour of the adrenal gland

If tumour of the adrenal gland is found out, and its size is more than 1 cm, first of all it is necessary to exclude or confirm the hormonal activity of the formation, that can be testified by hypercatecholamia, ACTH-independent hypercorticism, primary hyperaldosteronism.

At the second stage of diagnostics of malignant potential of tumour the evaluation of quantitative values of densitometry in case of three-phase MSCT:

• density of tissue component before using dye (a contrast substance) (native);
• density in the tissue phase of contrasting (arterial and venous phase);
• density in the postponed phase (in 10 minutes after introduction of dye (phase of washing off of dye).

If during the native phase there is high density, delay of dye in the postponed phase, probability of malignancy is high.

When there is a differentiated diagnosis of tumours of the adrenal gland, taking biopsy has no proving advantages, it is associated with the low sensibility, specificity and high probability of complications. The same thing regarding the diagnostic method PET CT; it has been found out that not all the neuroendocrine malignant tumours of the adrenal gland accumulate dye; thus, this method is not specific and reliable , and can give false negative result.

Indications for surgical treatment of tumour of the adrenal gland

The Indication for operation in case of neoplasms of the adrenal gland is:

• marked clinical syndrome and its progressing, related to hormonal activity of tumour, and it does not depend on the size of it;
• suspicion that tumour is malignant: fast progressing of the size of neoplasm in case of dynamic follow-up (1 cm per year or 0.5 cm within 6 months), considerable size of neoplasm, determined during the primary investigation (3-4 cm and more), CT-symptoms of malignant nature of tumour (tuberosity of contours, density of tissue, presence of blood flow, accumulation of dye, etc);
• bilateral lesion of the adrenal gland.

Surgical treatment of tumour (neoplasm) of the adrenal gland

If tumour of the adrenal gland is found out, and there are innumerated above indications for operation, then operation should be performed on; in this case 3 accesses are used: laparotomy, laparoscopy, lumboscopy. In all the cases operations can be organ-preserving (partial adrenalectomy with the tumour or cyst), or with the removal of organ (adrenalectomy).

Nowadays the majority of American and European surgeons use organ-preserving laparoscopic operations for adrenal gland. It is related to the desire of a patient to preserve the resourses of tissue of the adrenal gland, it provides the higher quality of life-reaction for stress, etc, and absence of substitutional hormonal therapy in case of bilateral lesion of organs and easier course of postoperation period. But they mention both of negative factors-the risk of leaving tumour, if its multifocal (multiple) lesion (less than 1%), probability of relapse development of cyst or tumour in remaining tissue (less than 2%) and more complex hemostasis in the zone of resection during operation. All these negative moments one can neutralize in the following way: a careful investigation and selection of patients before the operation (NMR, CT, hormonal screening, etc.), the use of contemporary electrosurgical systems (‘LigaSure”) and ultrasonic scissors for performing on safer resection of the adrenal gland, the use of the additional methods of hemostasis of the surface of the adrenal gland, hemostatic means-PerClot (Italy). A great importance in decreasing of intraoperation complications belongs to perfect manual habits of the operating surgeon.

Thus, partial laparoscopic adrenalectomy is indicated in case of benign hormonally active and non-active neoplasms of the adrenal gland without symptoms of invasion to the surrounding tissues, having the diameter 1.5-6.0 cm, located in the central and lateral parts of the adrenal gland. Contraindication for organ-preserving operation is multifocal lesion (up to 8%-in case of aldosterone-producing tumours and 15-20% in patients with hereditary syndromes-multiple endocrine neoplasms (MEN-2) and Hippel-Landau disease (VHL), and in case of cancer of the adrenal gland.

Fig.1. Location of tumour in the lateral pedicle of the adrenal gland. Partial adrenalectomy with preserving the organ.

The most modern way of treatment of diseases of the adrenal gland is a laparoscopic operation. It is performed via small punctures on the abdominal wall. A laparoscopic operation gives a possibility to visualize the adrenal gland,vessels in the zone of interference and the pathological neoplasms. The important advantage of the laparoscopic access (via abdomen) is a possibility to expose and ligate vessels fast before proceeding to the main stage, related to tumour, it makes the operation safe and fast. When using this access, a surgeon first deals with vessels, then-with the tumour. It is important in case of hormone-producing neoplasms, but not vice versa, as it takes place in case of lumboscopic access (using the lumbar area).

The stages of partial organ-preserving right adrenalectomy (a patient is in his supinal position), 4 ports are used (5-10 mm):

• the right lobe of liver is lifted by means of a retractor;
• duodenum is mobilized according to Kocher;
• the anterior wall of the inferior vena cava and that of the renal vein are exposed;
• the upper pole of kidney and the lower edge of the adrenal gland with its central vein are visualized;
• the revision of the organ is done, and tumour is found out; its location relatively to the tissue of the adrenal gland is learned in detail;
• then, using “LigaSure” apparatus, the exposure of the necessary area of the adrenal gland for further resection is done, then ligation and transection of the arterial and venous vessels;
• then resection of the adrenal gland alongside with tumour or enucleation of cyst by means of “LigaSure” apparatus (5 mm) is done with the further point hemostasis by a bipolar pincet and the use of hemostatics;
• the preparation is placed into the container and is removed from the abdominal cavity;
• later the checking of hemostasis is done in the zone of operation;
• if there are indications, draining of the abdominal cavity should be done (as to me, I rarely do it).

The stages of the partial organ-preserving left adrenalectomy (a patient is in the supinal position), 4 ports are used (5-10 mm):

• colon is mobilized and is stretched medially;
• the anterior wall of the inferior vena cava and that of the renal vein are exposed;
• the upper pole of kidney and the lower edge of the adrenal gland with its central vein are visualized;
• then the revision of the organ is done, and tumour is found out; its localization relatively to tissue of the adrenal gland is studied in detail;
• using “LigaSure” apparatus, the exposure of the necessary area of the adrenal gland for further resection is done, as well as ligation and transection of the arterial and venous vessels;
• then resection of the adrenal gland alongside with the tumour or enucleation of the cyst by means of the “LigaSure” apparatus (5 mm) is done with the further point hemostasis by a bipolar pincet and the use of hemostatics;
• the preparation is placed into the container and is evacuated from the abdominal cavity;
• then checking of hemostasis of operation zone is done; if there are indications, draining of the abdominal cavity should be done (as to me, I rarely do it).

Operation duration is 25-60 minutes, using general anesthesia; the constant follow-up of BP and narcosis is done.

Fig. 2. Localization of tumour in the centre of the adrenal gland. The partial adrenalectomy with preserving the parts of an organ.

Fig. 3. Localization of tumour in the medial pedicle of the adrenal gland. Adrenalectomy is being performed (removal of the adrenal gland).

The technique of laparoscopic organ-preserving operations during removal of the tumour of the adrenal gland is presented schematically at these pictures. If the pathological formation is located in the lateral pedicle of the adrenal gland (far from the nourishing vessels), as a rule, there are no problems with leaving tissue of the adrenal gland, as the line of organ resection (it is shown by a dotted line) passes between the tumour and the unchanged tissue (Fig. 1). If formation is located in the centre of the adrenal gland, I am able to preserve an organ and to perform on resection, leaving up to 40 % of healthy tissue ( a resection line is marked by a dotted line) (Fig. 2). If the pathological formation is localized in the port of the adrenal gland (where there are the main vessels, nourishing the organ), I am obliged to perform on adrenalectomy - removal of the whole of the organ, as the remained lateral part will not be able to get an adequate blood supply, and necrosis of this part will develop (Fig. 3).

As there is rather high risk of presence of single malignant cells, that can be found out only in case of histological investigation, in our clinic all operations are performed on, minding strict rules of ablastics. Preparation is always removed from the abdominal cavity in a special plastic container.

In some cases, for example, if it is a big tumour, and it is located in the port of the adrenal gland, we perform on not partial, but total adrenalectomy (removal of the whole of the adrenal gland).

Next day after operation we allow our patients to take food in accordance with the recommendations of the diet table # 1a, and starting from the third day – to take usual food. Starting from the first day, patients get up from their beds. Pain-killers stop working in majority of patients in 5-6 hours after operation; after that a patient will feel some discomfort at the area of operation, and in most cases it is not required to administer pain-killers.

After operations for removal of tumour or cyst of the adrenal gland histological investigation of the material should be done compulsory for final understanding of the kind of removed formation.

Operations for removal of tumour of the adrenal gland are accompanied by an excellent cosmetic effect, as while using laparoscopic technique, only 3-4 punctures, having the length 5-10 mm, are left on the skin of abdomen; and during the operation the techniques of plasty surgery are used, including placing cosmetic sutures.

If you want to make an appointment with the doctor,

please, call the tel: +7 495 222-10-87 +7 903 798-93-08 Olga - that is my assistant.

Or you may use my e-address: puchkovkv@mail.ru puchkovkv@mail.ru copy

«When you write me letters, you should be sure that all of them will find themselves in my e-mail. I always reply your letters myself. I remember that you trust me the most precious things - your health, your fate, your family, your nearest and dearest, and I always try to do my best to justify your trust.

Every day I answer your letters, and it takes me several hours.

When you write me letters, you can be sure, that I will learn your situation very attentively, in case of need I will ask for some additional medical documents.

A great clinical experience and thousands of successful operations will give me a possibility to understand your problem even at some distance. Many patients need not surgical treatment, but properly administered conservative treatment, but some patients need urgent surgery. In both cases I would recommend additional investigations in case of need or admitting to hospital. It is important to bear in mind that some patients need preliminary treatment of accompanying diseases in order to have a successful operation.

In your letter, please, mention your age, main complaints, your place of residence, telephone number and e-mail.

For me to be able to give you a full answer, please, forward me a scanned conclusion of USI, CT, MRT alongside with your question, as well as conclusions of other specialists. After studying your case I will forward you either my detailed reply, or a letter with some additional questions to clarify the situation. Anyhow, I will try to help you and justify your hope and trust that are the most important things for me.

Sincerely, your

surgeon Konstantin Puchkov»