Clinically inapparent adrenal masses are incidentally detected after imaging studies conducted for reasons other than the evaluation of the adrenal glands. They have frequently been referred to as adrenal incidentalomas. In preparation for a National Institutes of Health State-of-the-Science Conference on this topic, extensive literature research, including Medline, BIOSIS, and Embase between 1966 and July 2002, as well as references of published metaanalyses and selected review articles identified more than 5400 citations. Based on 699 articles that were retrieved for further examination, we provide a comprehensive update of the diagnostic and therapeutic approaches focusing on endocrine and radiological features as well as surgical options. In addition, we present recent developments in the discovery of tumor markers, endocrine testing for subclinical disease including autonomous glucocorticoid hypersecretion and silent pheochromocytoma, novel imaging techniques, and minimally invasive surgery. Based on the statements of the conference, the available literature, and ongoing studies, our aim is to provide practical recommendations for the management of this common entity and to highlight areas for future studies and research.

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The Clinically Inapparent Adrenal Mass: Update in Diagnosis and Management

American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons Medical Guidelines for the Management of Adrenal Incidentalomas

Posterior retroperitoneoscopic adrenalectomy--results of 560 procedures in 520 patients.

American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons Medical Guidelines for the Management of Adrenal Incidentalomas: Executive Summary of Recommendations

Pheochromocytomas are rare, mostly benign catecholamine-producing tumors of chromaffin cells of the adrenal medulla or of a paraganglion. Typical clinical manifestations are sustained or paroxysmal hypertension, severe headaches, palpitations and sweating resulting from hormone excess. However, their presentation is highly variable and can mimic many other diseases. If remaining unrecognized or untreated, they can be a life-threatening condition. Therefore, the most important message of this review is to think of them. The diagnosis of pheochromocytomas depends mainly upon the demonstration of catecholamine excess by 24-h urinary catecholamines and metanephrines or plasma metanephrines. They are localized by a computed tomography scan and magnetic resonance imaging of the adrenal glands and abdomen; complementary 123I-metaiodobenzylguanidine scintigraphy and 18F-dihydroxyphenylalanine-positron emission tomography are available. Because approximately one out of four pheochromocytomas turn out to be hereditary entities, screening for genetic alterations is important. Laparoscopic and adrenal sparing surgical intervention following preoperative alpha-blockade is the treatment of choice and usually curative. In malignant pheochromocytomas, radiotherapy and chemotherapy are palliative treatment options. This review provides an update on identification and management of pheochromocytomas, emphasizing current developments in diagnosis, including genetic testing, pathophysiology and treatment of pheochromocytomas.

Pheochromocytoma: presentation, diagnosis and treatment

Posterior retroperitoneoscopic adrenalectomy is one of the new endoscopic methods in endocrine surgery In a prospective clinical study 142 posterior retroperitoneoscopic adrenalectomies (72 right, 70 left) were performed in 130 patients (52 males, 78 females, age 491 ± 149 years) Indications were primary adrenal tumors (unilateral, n= 118; bilateral, n= 2), adrenal metastases (n= 2), and bilateral ACTH-dependent hyperplasias (n= 10) Tumor size ranged from 05 to 70 cm (mean 27 ± 14 cm) Partial adrenalectomies were performed in 39 patients Conversion to open posterior adrenalectomy was necessary in five patients and seven procedures (5%) Intraoperative and postoperative complications were minor and occurred in 5% and 13%, respectively Mortality was zero Operating time was 101 ± 39 minutes (range 35–285 minutes) and depended on tumor type (pheochromocytoma versus others; p < 001), tumor size (< 3 vs ≥ 3 cm; p < 005), gender (p < 005), and extent of resection (partial versus complete, p < 005 Twenty-three adrenalectomies (17%) were performed within 1 hour or less Blood loss was 54 ± 72 ml Consumption of analgesics was low (mean 6 mg piritramide postoperatively) Median duration of hospitalization was 3 days Posterior retroperitoneoscopic adrenalectomy is a safe method that has become a standard procedure in endocrine surgery

Christoph E. Broelsch

Papers

Posterior Retroperitoneoscopic Adrenalectomy: Lessons Learned within Five Years