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In general, patients with incidentalomas are managed depending on several factors such as tumor size, functional status, and the likely pathology. The group with malignant adrenal disease poses a challenge to management. Patients with widely disseminated disease and adrenal metastases may receive systemic chemotherapy or immunotherapy, external beam radiation for bone pain from vertebral bone erosions, or just supportive palliative care because of advanced disease. However, some centers advocate a selective approach in resecting solitary adrenal metastasis (without metastasis to other organs) provided that the primary disease is adequately controlled and a reasonable disease-free interval is achieved.4,5 For patients with primary adrenocortical carcinomas, complete surgical excision combined with chemotherapy offers the best chance for potentially curative therapy against this aggressive and usually fatal tumor. Provided that the patient has no metastatic disease, an en bloc clearance of the adrenal cancer and regional nodes via an abdominal approach is performed.

It is generally agreed that all functioning tumors should be removed to prevent progression of the disease. The specific preoperative, operative, and postoperative care varies depending on the type of tumor being treated.

There has been considerable discussion as to the most effective treatment of patients with a nonfunc-tioning incidentaloma. As the pathology and natural history of such lesions cannot be predicted with accuracy, the size of the tumor (which correlates with the risk of adrenal carcinoma) is central in deciding which lesions should be removed or observed. A large tumor has a higher chance of being an adrenal carcinoma than a smaller tumor, and the risk increases with tumors larger than 5 cm. One study of 38 patients showed that the incidence of adrenal cancers larger or smaller than 5 cm was 87% and 13%, respectively.6 Adrenalectomy is recommended in patients with these large tumors. Such a risk is considerably lower, although not eliminated, in tumors smaller than 3 cm in diameter. These tumors are not removed, unless associated with other characteristics of cancer as mentioned above, but

Figure 12-7. A 47-year-old woman had a 2 cm right adrenal tumor discovered incidentally 2 years ago and had a negative biochemical workup. A, A follow-up abdominal computed tomographic scan 2 years later showed the right adrenal tumor (large white arrow) to have grown to 3.5 cm. The left adrenal gland (small white arroW) was normal. Biochemical workup again showed no hyper-function. She underwent a laparoscopic right adrenalectomy. B, Pathology showed it to be a adrenocortical adenoma.

Figure 12-7. A 47-year-old woman had a 2 cm right adrenal tumor discovered incidentally 2 years ago and had a negative biochemical workup. A, A follow-up abdominal computed tomographic scan 2 years later showed the right adrenal tumor (large white arrow) to have grown to 3.5 cm. The left adrenal gland (small white arroW) was normal. Biochemical workup again showed no hyper-function. She underwent a laparoscopic right adrenalectomy. B, Pathology showed it to be a adrenocortical adenoma.

monitored for growth or subsequent function with imaging scans and biochemical testing (Figure 12-7). Regular surveillance is important because cancers that start as small tumors are often misdiagnosed as benign. A lesion that continues to grow or becomes functional should be removed. Nonfunctioning tumors that measure between 3 and 5 cm can be approached in two ways. The first is nonoperative management, such as in the elderly patient with medical conditions that contraindicate surgery, in which the patient undergoes regular surveillance. The second approach is to perform adrenalectomy, especially in the younger patient, who benefits because (1) the lesion is removed, (2) the chance for the tumor to become functional or cancerous is removed, (3) there is a decreased need for regular imaging or biochemical tests that contribute to ongoing costs, and (4) adrenal tumors are more likely to be malignant in young patients. Such a management plan varies among different physicians and institutions and is generally determined by patient selection, surgeon's expertise, and low complication rates of surgery.

Laparoscopic adrenalectomy achieves complete adrenal resection and is ideal for benign solitary tumors smaller than 8 to 10 cm in diameter (Table 12-4). When compared with open surgery, the laparo-scopic approach causes less pain and disability to patients and allows them to leave hospital early to resume work and normal activities.7,8 The most popular method of laparoscopic adrenalectomy is the transabdominal approach with the patient in the lateral position. During laparoscopic adrenalectomy, care should be taken not to breach the capsule of the tumor to prevent tumor cell seeding. Periadrenal tissue should be resected with all of the adrenal gland. Other surgical approaches are the laparoscopic posterior adrenalectomy and the open posterior retroperitoneal

Table 12-4. BENEFITS OF LAPAROSCOPIC ADRENALECTOMY

Small operative wounds Minimal postoperative pain Short hospital stay Rapid recovery

Early return to normal activities High rate of success Low rate of complications approach. Very large tumors (more than 10 cm) or known adrenal carcinomas should be removed via the anterior or lateral laparotomy or via a thoracoabdominal incision to ensure complete and adequate tumor clearance. Open adrenalectomy is also recommended for small tumors if there is obvious local invasion from preoperative imaging studies. Similarly, the laparo-scopic approach may need to be converted to the open approach during adrenalectomy for a more complete resection, especially if adjacent organs are invaded.

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