Editorial Comment
Editorial Comment to Clinical and imaging overview of functional adrenal neoplasms
Although Low and Sahi stated that the treatment for patients with bilateral functioning tumors was adrenal- preserving surgery,1 management of those patients remains controversial.
The most common indications for bilateral adrenalectomy include adrenocorticotropic hormone (ACTH)-dependent adrenal hyperplasia (Cushing’s disease) after failed hypo- physectomy and ectopic ACTH production.2 In the literature reviews comprising 150 patients who underwent bilateral adrenalectomy, this was the surgical indication in 80-90% of patients.2 Rare causes include bilateral pheochromocy- toma in patients with multiple endocrine neoplasia type 2 (MEN 2) and von Hippel-Lindau syndrome.3 Furthermore, it has been reported that definitive treatment for ACTH- independent macronodular adrenal hyperplasia (AIMAH) or primary pigmented nodular adrenocortical disease (PPNAD) is bilateral total adrenalectomy.4 Rare cures after unilateral adrenalectomy are suspect, and persistent gluco- corticoid autonomy is likely.4 However, these patients who undergo bilateral adrenalectomy require intense postopera- tive care and lifelong glucocorticoid and mineralocorticoid replacement. In addition, most of these patients have lived with hypercortisol-secreting adenomas for many years, and are at high risk for perioperative complications.
To avoid the short- and long-term metabolic and hor- monal complications associated with removal of both adrenal glands, laparoscopic partial adrenalectomy has been described for bilateral pheochromocytoma5,6 and Cushing’s syndrome caused by bilateral adenomas.7 Adrenal-sparing procedures, therefore, might offer improved quality of life and reduced long-term morbidity. Laparoscopic partial adrenalectomy is of significant relevance for those with increased genetic risk of pheochromocytomas. Diner et al. reviewed the National Cancer Institute experience of patients with hereditary pheochromocytomas who under- went simultaneous bilateral partial adrenalectomy.8 However, partial adrenalectomy increases the risk of pheo- chromocytoma recurrence and is inappropriate for patients with ACTH-dependent bilateral cortical hyperplasia.3
Among patients with primary hyperaldosteronism (PHA) as a result of bilateral hyperplasia who underwent unilateral adrenalectomy based on the findings of selective venous catheterization, 35% had a normalization or improvement of hypertension postoperatively.9 These data suggest that uni- lateral adrenalectomy can be beneficial in some patients with PHA as a result of bilateral hyperplasia, and also pro- vided that there is a rigorous determination of which side should be resected.9
Finally, no guidelines exist regarding acceptable indica- tions for which adrenal masses are more suitable for treat- ment with an adrenal-sparing approach.10
Soichi Mugiya M.D. Department of Urology, Hamamatsu University School of Medicine, Higashi-ku, Hamamatsu, Japan mugiya@hama-med.ac.jp
DOI: 10.1111/j.1442-2042.2012.03051.x
Conflict of interest
None declared.
References
1 Low G, Sahi K. Clinical and imaging overview of functional adrenal neoplasms. Int. J. Urol. 2012; doi: 10.1111/j.1442-2042.2012.03014.x.
2 Germain A, Klein M, Brunaud L. Surgical management of adrenal tumors. J. Vasc. Surg. 2011; 148: 250-61.
3 Takata MC, Kebebew E, Clark OH, Duh QY. Laparoscopic bilateral adrenalectomy: results for 30 consecutive cases. Surg. Endosc. 2008; 22: 202-7.
4 Lacroix A, Bourdeau I. Bilateral adrenal Cushing’s syndrome: macronodular adrenal hyperplasia and primary pigmented nodular adrenocortical disease. Endocrinol. Metab. Clin. North Am. 2005; 34: 441-58.
5 Radmayr C, Neumann H, Bartsch G, Elsner R, Janetschek G. Laparoscopic partial adrenalectomy for bilateral pheochromocytomas in a boy with von Hippel-Lindau disease. Eur. Urol. 2000; 38: 344-8.
6 Kaouk JH, Matin S, Bravo EL, Gill IS. Laparoscopic bilateral partial adrenalectomy for pheochromocytoma. Urology 2002; 60: 1100-3.
7 Inoue T, Ishiguro K, Suda T et al. Laparoscopic bilateral partial adrenalectomy for adrenocortical adenomas causing Cushing’s syndrome: report of a case. Surg. Today 2006; 34: 94-7.
8 Diner E, Franks M, Behari A et al. Partial adrenalectomy: the National Cancer Institute experience. Urology 2005; 66: 19-23.
9 Sukor N, Gordon R, Ku YK, Jones M, Stowasser M. Role of unilateral adrenalectomy in bilateral primary hyperaldosteronism: a 22-year single center experience. J. Clin. Endocrinol. Metab. 2009; 94: 2437-45.
10 Disick GIS, Munver R. Adrenal-preserving minimally invasive surgery: update on the current status of laparoscopic partial Adrenalectomy. Curr. Urol. Rep. 2008; 9: 67-72.
@ 2012 The Japanese Urological Association