American Association of Endocrine Surgeons Guidelines for Adrenalectomy

Abstract

ImportanceAdrenalectomy is the definitive treatment for multiple adrenal abnormalities. Advances in technology and genomics and an improved understanding of adrenal pathophysiology have altered operative techniques and indications.ObjectiveTo develop evidence-based recommendations to enhance the appropriate, safe, and effective approaches to adrenalectomy.Evidence ReviewA multidisciplinary panel identified and investigated 7 categories of relevant clinical concern to practicing surgeons. Questions were structured in the framework Population, Intervention/Exposure, Comparison, and Outcome, and a guided review of medical literature from PubMed and/or Embase from 1980 to 2021 was performed. Recommendations were developed using Grading of Recommendations, Assessment, Development and Evaluation methodology and were discussed until consensus, and patient advocacy representation was included.FindingsPatients with an adrenal incidentaloma 1 cm or larger should undergo biochemical testing and further imaging characterization. Adrenal protocol computed tomography (CT) should be used to stratify malignancy risk and concern for pheochromocytoma. Routine scheduled follow-up of a nonfunctional adrenal nodule with benign imaging characteristics and unenhanced CT with Hounsfield units less than 10 is not suggested. When unilateral disease is present, laparoscopic adrenalectomy is recommended for patients with primary aldosteronism or autonomous cortisol secretion. Patients with clinical and radiographic findings consistent with adrenocortical carcinoma should be treated at high-volume multidisciplinary centers to optimize outcomes, including, when possible, a complete R0 resection without tumor disruption, which may require en bloc radical resection. Selective or nonselective α blockade can be used to safely prepare patients for surgical resection of paraganglioma/pheochromocytoma. Empirical perioperative glucocorticoid replacement therapy is indicated for patients with overt Cushing syndrome, but for patients with mild autonomous cortisol secretion, postoperative day 1 morning cortisol or cosyntropin stimulation testing can be used to determine the need for glucocorticoid replacement therapy. When patient and tumor variables are appropriate, we recommend minimally invasive adrenalectomy over open adrenalectomy because of improved perioperative morbidity. Minimally invasive adrenalectomy can be achieved either via a retroperitoneal or transperitoneal approach depending on surgeon expertise, as well as tumor and patient characteristics.Conclusions and RelevanceTwenty-six clinically relevant and evidence-based recommendations are provided to assist surgeons with perioperative adrenal care.

Pitfalls in the diagnosis and treatment of a hypertensive patient with unilateral primary aldosteronism and contralateral pheochromocytoma: a case report

“…This difference posed a significant challenge for simultaneous diagnosis. However, since the urinary fractionated metanephrines levels were already between the upper limit of the normal range and the diagnostic level and the CT attenuation of the left adrenal nodule was more than 30 HU at the first admission, we should have performed an additional investigation including a clonidine suppression test for adrenal nodules with possible pheochromocytoma [ 16 , 17 ]. Instead, we decided to do a close follow-up, but unfortunately, she interrupted it.…”

Giant Adrenal Myelolipoma and Congenital Adrenal Hyperplasia: a Case Report and Review of the Literature

“…Based on recent guidelines from the American Association of Endocrine Surgeons, adrenal myelolipomas are recommended for resection when the lesions are symptomatic from mass effect or bleeding and if there is interval growth on surveillance imaging [21]. Case studies have described a rare complication of spontaneous rupture and hemorrhage that is more likely to occur in myelolipomas > 10 cm in diameter.…”

Construction and validation of a prognostic model for predicting overall survival of primary adrenal malignant tumor patients: A population-based study with 1,080 patients

“…Accordingly, partial adrenalectomy may be considered when clinical specifications are followed ( 51 ). Distinct from most previous studies, our histological type included both ACC originating from the adrenal cortex and PHEO from the adrenal medulla ( 52 , 53 ). The reason for including two heterogeneous histological types in this study, in addition to validating previous findings that PHEO has a better prognosis than ACC, was mainly because we wanted to make a simple-to-use model for clinical workers.…”