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• Juan J. Sancho 1
• Frédéric Triponez 2
• Xavier Montet 3
• Antonio Sitges-Serra 1
(1) Endocrine Unit. Hospital del Mar. Universitat Autònoma de Barcelona. Barcelona. Spain.
(2) Chirurgie thoracique et endocrinienne. Hôpitaux Universitaires de Genève. Genève. Switzerland.(3) Department of Radiology. Hôpitaux Universitaires de Genève. Genève. Switzerland.
Surgical Managementof Adrenal Metastases
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• Introduction• Prevalence• Origin• Clinical manifestations
• Imaging techniques
• Percutaneous biopsy
• Surgical Treatment• Indications• Prognosis• Approach
• Non Surgical options
Surgical Managementof Adrenal Metastases
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• Introduction• Prevalence• Origin• Clinical manifestations
• Imaging techniques
• Percutaneous biopsy
• Surgical Treatment• Indications• Prognosis• Approach
• Non Surgical options
Surgical Managementof Adrenal Metastases
The dimensions of the Problem
Where do they come from ?
When we have to be alert ?
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10% to 27% of patients dying from cancer
•PrevalenceIntroduction
The dimensions of the Problem
Abrams HL, Spiro R, Goldstein N. Metastases in carcinoma; analysis of 1000 autopsied cases. Cancer 1950;3(1):74-85.
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•PrevalenceIntroduction
The dimensions of the Problem
Abrams HL, Spiro R, Goldstein N. Metastases in carcinoma; analysis of 1000 autopsied cases. Cancer 1950;3(1):74-85.
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•PrevalenceIntroduction
The dimensions of the Problem
Adenoma41%
Metastases19%
Adrenocortical carcinoma
10%
Myelolipoma9%
Pheochromocytoma8%
Other13%
Distribution of diagnosed adrenal masses
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•Prevalence
Why?
– Multiple arterial supply
– Intricate lymphatic network
– Rich sinusoidal blood flow
Introduction
The dimensions of the Problem
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Introduction• Prevalence• Origin
Where do they come from ?
LUNG29%
BREAST26%
SKIN14%
KIDNEY10%
LIVER7%
GI TRACT6%
SOFT TISSUES3%
OTHER5%
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Where do they come from ?
Lam KY, Lo CY. Metastatic tumours of the adrenal glands: a 30-year experience in a teaching hospital. Clin Endocrinol (Oxf). 2002;56:95-101.
Introduction• Prevalence• Origin
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Introduction
Where do they come from ?
• Prevalence• Origin
Onuigbo WI. Lymphangiogenesis may explain adrenal selectivity in lung cancer metastases. Med Hypotheses 2010;75:185-6.
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Introduction
When must we be alert?
• Prevalence• Origin• Clinical manifestations
95 % clinically silent
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Introduction
When must we be alert?
• Prevalence• Origin• Clinical manifestations
95 % clinically silent
Pain- Hemorrage ?
- Melanoma ?
Adrenal insufficiency- Occasionally Addisonian crisis
- Must be bilateral
- May be masked in advanced malignancies
Bretcha-Boix P et al. Surgical treatment of lung cancer with adrenal metastasis. Lung Cancer 2000;27:101-5.
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Incidentaloma
in a non*
CancerPatient
AM in a
CancerPatient
Imagein a
CancerPatient
Introduction• Prevalence• Origin• Clinical manifestations
1. Is it a metastasis?
2. Is it the only one?
1. Is it the only one?
1. Is it hypersecreting?
2. Is it malignant?
3. Is it a metastasis?
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Incidentaloma
in a non*
CancerPatient
Introduction• Prevalence• Origin• Clinical manifestations
1. Is it hypersecreting?
2. Is it malignant?
3. Is it a metastasis?
Lee JE et al. Unknown primary cancer presenting as an adrenal mass: frequency and implications for diagnostic evaluation of adrenal incidentalomas. Surgery 1998;124:1115-22.
1715 referrals for suspected unknown
primary cancer
76
NO cancer1693Cancer
95 (5.8%)
AM
• 4 (0.2%) AM only
• 4/4 >6 cm
• 3/4 bilateral
• 4/4 symptoms
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Incidentaloma
in a non*
CancerPatient
AM in a
CancerPatient
Imagein a
CancerPatient
Introduction• Prevalence• Origin• Clinical manifestations
1. Is it a metastasis?
2. Is it the only one?
1. Is it the only one?
1. Is it hypersecreting?
2. Is it malignant?
3. Is it a metastasis?
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Management Plan
Incidentaloma
in a non*
CancerPatient
AM in a
CancerPatient
Imagein a
CancerPatient
Introduction• Prevalence• Origin• Clinical manifestations