Adrenal Surgery in the Era of Multidisciplinary Endocrine Tumor Boards

Abstract

Work up of adrenal masses includes assessment of endocrine activity and malignancy risk. There is no indication for surgical removal of nonfunctional adrenal adenomas, according to the guidelines. In the present study, we aimed at evaluating the impact of a university endocrine tumor board on the quality of the indications for adrenal surgery at our institution. One hundred consecutive patients receiving primary adrenal surgery at the University Hospital of Cologne, Germany were included. Their demographics, clinic-pathologic characteristics, treatment and outcome were analyzed. In 55 (55%) cases, indication for surgery consisted in functional benign tumors, including Conn, Cushing adenomas and pheochromocytomas. Forty (40%) tumors were referred to surgery for malignancy suspicion and 5 (5%) myelolipomas were removed due to their size. Eighty-nine percent of surgeries were performed as minimally invasive procedures. Overall morbidity included two (2%) self-limiting pancreatic fistulas after left laparoscopic adrenalectomy for pheochromocytoma. All functional tumors were confirmed benign by final histology. Only 33 (82.5%) of 40 suspicious cases turned out to be malignant. Consequently, nonfunctional benign adenomas were “unnecessarily” removed in only 7 (7%) patients, with 6 (85.7%) of them having a history of extra-adrenal cancer and all of them fulfilling criteria for surgery, according to the international guidelines. In conclusion, the endocrine tumor board provided an excellent adherence to the guidelines with most surgeries being performed either for functional or malignant tumors. In nonfunctional tumors with history of extra adrenal cancer, CT guided biopsy might be considered for obviating surgery.

Key words

adrenal mass - adrenal adenoma - incidentaloma - adrenal tumor

Publication History

Received: 30 December 2021

Accepted after revision: 16 March 2022

Article published online:
09 May 2022

• References

• 1 Kebebew E. Adrenal incidentaloma. N Engl J Med 2021; 384: 1542-1551
• 2 Sherlock M, Scarsbrook A, Abbas A. et al. Adrenal incidentaloma. Endocr Rev 2020; 41: 775-820
• 3 Ichijo T, Ueshiba H, Nawata H. et al. A nationwide survey of adrenal incidentalomas in Japan: the first report of clinical and epidemiological features. Endocr J 2020; 67: 141-152
• 4 Elhassan YS, Alahdab F, Prete A. et al. Natural history of adrenal incidentalomas with and without mild autonomous cortisol excess. A systematic review and meta-analysis. Ann Intern Med 2019; 171: 107-116
• 5 Fassnacht M, Arlt W, Bancos I. et al. Management of adrenal incidentalomas: European society of endocrinology clinical practice guideline in collaboration with the European network for the study of adrenal tumors. Eur J Endocrinol 2016; 175: G1-G34
• 6 Karas PL, Rankin NM, Stone E. Medicolegal considerations in multidisciplinary cancer care. JTO Clin Res Rep 2020; 1: 100073
• 7 Murray PV, O’Brien MER, Sayer R. et al. The pathway study: results of a pilot feasibility study in patients suspected of having lung carcinoma investigated in a conventional chest clinic setting compared to a centralised two-stop pathway. Lung Cancer 2003; 42: 283-290
• 8 Conron M, Phuah S, Steinfort D. et al. Analysis of multidisciplinary lung cancer practice. Intern Med J 2007; 37: 18-25
• 9 Leo F, Venissac N, Poudenx M. et al. Multidisciplinary management of lung cancer: how to test its efficacy?. J Thorac Oncol 2007; 2: 69-72
• 10 Sidhom MA, Poulsen MG. Group decisions in oncology: doctors’ perceptions of the legal responsibilities arising from multidisciplinary meetings. J Med Imaging Radiat Oncol 2008; 52: 287-292
• 11 Freeman RK, Van Woerkom JM, Vyverberg A. et al. The effect of a multidisciplinary thoracic malignancy conference on the treatment of patients with lung cancer. Eur J Cardio-thoracic Surg 2010; 38: 1-5
• 12 Boxer MM, Vinod SK, Shafiq J. et al. Do multidisciplinary team meetings make a difference in the management of lung cancer?. Cancer 2011; 117: 5112-5120
• 13 Gebbia V, Guarini A, Piazza D. et al. Virtual multidisciplinary tumor boards: a narrative review focused on lung cancer. Pulm Ther 2021; 7: 295-308
• 14 Savitz A, Fong B, Hochberg A. et al. Endocrine tumor board: ten years’ experience of a multidisciplinary clinical working conference. Perm J 2020; 24: 19.140
• 15 Kelley S, Beck AC, Weigel RJ. et al. Influence of endocrine multidisciplinary tumor board on patient management and treatment decision making. Am J Surg 2022; 223: 76-80
• 16 Walz MK, Peitgen K, Krause U. et al. Die dorsale retroperitoneoskopische Adrenalektomie – eine neue operative Technik [Dorsal retroperitoneoscopic adrenalectomy – a new surgical technique]. Zentralbl Chir 1995; 120: 53-58
• 17 Lee CR, Walz MK, Park S. et al. A comparative study of the transperitoneal and posterior retroperitoneal approaches for laparoscopic adrenalectomy for adrenal tumors. Ann Surg Oncol 2012; 19: 2629-2634
• 18 Alesina PF, Walz MK. Adrenal tumors: are gender aspects relevant?. Visc Med 2020; 36: 15-19
• 19 Staubitz JI, Clerici T, Riss P. et al. EUROCRINE®: adrenal surgery 2015–2019 – surprising initial results. Der Chir 2021; 92: 448-463
• 20 Lee JM, Kim MK, Ko SH. et al. Clinical guidelines for the management of adrenal incidentaloma. Endocrinol Metab 2017; 32: 200-218
• 21 Schloetelburg W, Ebert I, Petritsch B. et al. Adrenal wash-out CT: moderate diagnostic value in distinguishing benign from malignant adrenal masses. Eur J Endocrinol 2022; 186: 183-193
• 22 Bancos I, Taylor AE, Chortis V. et al. Urine steroid metabolomics for the differential diagnosis of adrenal incidentalomas in the EURINE-ACT study: a prospective test validation study. Lancet Diabetes Endocrinol 2020; 8: 773-781
• 23 Gruber LM, Strajina V, Bancos I. et al. Not all adrenal incidentalomas require biochemical testing to exclude pheochromocytoma: Mayo clinic experience and a meta-analysis. Gland Surg 2020; 9: 36271-36371
• 24 Ye YL, Yuan XX, Chen MK. et al. Management of adrenal incidentaloma: the role of adrenalectomy may be underestimated. BMC Surg 2016; 16: 1-6