A CASE OF CUSHING’S SYNDROME DUE TO ADRENOCORTICAL CARCINOMA WITH RECURRENCE 19 MONTHS AFTER LAPAROSCOPIC ADRENALECTOMY
TOMOMI USHIYAMA, KAZUO SUZUKI, SHINJI KAGEYAMA, KIMIO FUJITA, YUTAKA OKI AND TERUYA YOSHIMI
From the Department of Urology and Second Division Department of Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
KEY WORDS: laparoscopy, adrenalectomy, Cushing’s syndrome, adrenal cortical carcinoma
Although laparoscopic surgery is performed for minimally invasive treatment of adrenal tumors, indications for laparo- scopic adrenalectomy have not yet been clearly defined.1 We report on a patient with Cushing’s syndrome and adrenal tumor recurrence after laparoscopic adrenalectomy.
CASE REPORT
A 50-year-old woman was referred to our clinic with Cushing’s syndrome due to a left adrenal adenoma. Comput- erized tomography (CT) revealed a left adrenal tumor 5 cm. in diameter that was only slightly irregular and inhomoge- neous. On July 14, 1993 laparoscopic adrenalectomy was performed successfully without complication and the tumor was removed en bloc without any damage (fig. 1). Histological diagnosis was adrenocortical adenoma and the patient re- ceived steroid replacement until October.
Beginning in September 1994 the plasma cortisol level began to elevate as plasma adrenocorticotropic hormone gradually decreased. CT revealed multiple intra-abdominal and nodular lesions at the adrenalectomy site (fig. 2), which
Accepted for publication December 11, 1996.
were confirmed by repeat exploratory laparotomy. The pre- viously resected adrenal specimen was closely reexamined according to the criteria of Weiss et al,2 and diagnosis was changed to adrenocortical carcinoma. Chemotherapy with mitotane, carboplatin and etoposide improved hypercorti- solism and decreased the size of the intra-abdominal tumors.
DISCUSSION
Laparoscopic adrenalectomy was performed for a preoper- ative diagnosis of adrenal adenoma. Although it was removed en bloc without any damage to the lesion the tumor recurred. We believe that malignant adrenal tumors are not indicated for laparoscopic surgery. Adrenal carcinomas are generally larger than 5.5 to 6 cm. in diameter, are irregular in shape and have an inhomogeneous interior with low attenuation areas caused by focal hemorrhage and necrosis.3 Presently we believe that laparoscopic adrenalectomy may be indicated when the lesion is smaller than 6 cm. in diameter with a smooth contour and a homogeneous interior.
REFERENCES
1. Suzuki, K., Ushiyama, T., Fujita, K. and Kawabe, K .: Laparo- scopic adrenalectomy. Experiences with 50 patients. Urol. Ausgabe A, 35: 233, 1996.
2. Weiss, L. M., Medeiros, L. J. and Vickery, A. L., Jr .: Pathologic features of prognostic significance in adrenocortical carci- noma. Amer. J. Surg. Path., 13: 202, 1989.
3. Staren, E. D. and Prinz, R. A .: Selection of patients with adrenal incidentalomas for operation. Surg. Clin. N. Amer., 75: 499, 1995.