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The laparoscopic management of a primary adrenal malignant melanoma
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5 L A P A R O S C O P I C A D R E N A L E C T O M Y IN U R O L O G I C P R A C T I C E , A COMBINED C H I L E A N AND G E R M A N EXPERIENCE
L A P A R O S C O P I C A D R E N A L E C T O M Y ; EXPERIENCE OF 9 YEARS
Guzmfin S. 1, Hatzinger M. 2, Kamp S.2, Velasco A?, Haecker A.2, Gimdnez F. 1, Monteverde E. 1, Jeanneret V.1, Michel M.S.2, Alken R 2
Simforoosh N. Basiri A., Danesh A., Sharifi-Aghdas F., Ziaee S.A.M., Tabibi A., Nadj aft- Semnani M.
~E Universidad Cat61ica, Urology Department, Santiago, Chile, 2University of Mannheim, Urology Department, Mannheim, Germany
Shahid Beheshti University of Med Scie, Urology, Tehran, Iran
INTRODUCTION & OBJECTIVES: Laparoscopic adrenalectomy has become a standard of care in the last ten years. The purpose of this report is to analyze a combined Chilean and German institutional experience in laparoscopic adrenalectomy, with special attention to different approaches (transperituneal or retroperitoneal) as done with preference each centre.
I N T R O D U C T I O N & OBJECTIVES: We performed 45 laparoscopic adrenalectomy from October 1995 until June 2004 in Shahid Labbafinejad Medical Centre, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Hereby we describe our experience.
MATERIAL & METHODS: The clinical and pathological data from 32 patients who underwent Laparoscopic Adrenalectomy between September 1999 and September 2004 were reviewed. Two groups of patients were studied, a group operated in Chile through a transperitoneal approach, and a group operated in Germany mainly through a retroperitoneal approach. Surgery was indicated for all functional masses, and for incidental masses bigger than 3 cms in diameter or that showed change in radiologic follow-up.
M A T E R I A L & METHODS: 44 patients (30 female and 14 male) with mean age of 39.1 years (22-59) were presented. One female patient, known case of Cushing's disease who had failed transsphenoidal hypophysial surgery underwent simultaneous bilateral adrenalectomy. 9 patients were diagnosed incidentally to have adrenal mass. Hypertension was the chief complaint in 25 (57%) cases.
RESULTS: The series is composed of 32 patients, 60% male, 40% female, mean age of 50 years (27-68). Indication was: Incidental Tumour in 78%, 6.2% Cushing Syndrome, 12.5% Hyperaldosteronoma and 3% Pheocromocitoma. A Transperitoneal approach was used in 27 patients, in 5 a Retroperitoneal approach was used, selection was done upon surgeon's preference. Mean operative time was 130 minutes (50-240), and did not correlate with tumour size that ranged from 1 to 15 cms. There was also no significant time difference considering the surgical approach whether trails or retroperitoneal. Conversion rate was 12% (3 cases, 2 to open surgery and 1 to hand-assisted surgery). Mean in hospital stay was 2 days in the Chilean group and 4 in the German group. Pathologic analysis showed in 19 (59.14%) adrenal cortical adenoma, 1 (3.12%) adrenal carcinoma, 2 (6.25%) ganglioneuroma, 4 (12.5%) adrenal epithelial cyst, 2 (6.25%) mielolipoma, 1 (3.12%) supernumerary spleen, 1 (3.12%) inflammatory tumour, and 2 (6.25%) pheoeromocitoma The patient with an adrenal carcinoma had a 4 cms tumour that was an incidental finding in radiol0gieal controls. There was no mortality, with a significant morbidity of 3.12%, 1 patient that had a postoperative hemoperitoneum that needed revision.
RESULTS: Mean of maximum diameter and weight of adrenal mass were 5.7 (2.1-9.5) cm and 54 gm (3-379). Mean operation time for unilateral cases was 189 ± 58 minutes. Perioperative blood transfusion was required in 3 patients. Conversion to open surgery was needed in 5 (11%) and reoperation for hemorrhage was done in 1 case. There was one ileal injury in a patient with history of previous abdominal surgery and dense adhesions which repaired laparoscopically without any postoperative problem. All complications occurred in first 25 cases and there was no major complication in last 19 cases. Pathological diagnosis were pheochromocytoma in 18 (41%), aldosterone producing adenoma (APA) in 14 (31,8%), pseduoeyst in 5 (11.4), myelolipoma in 2, Schwannoma in 1, adrenal cyst in 1 and nodular cortical adrenal hyperplasia in case of bilateral adrenalectomy. Pathological diagnosis in incidentally diagnosis cases were APA in 2 patients, pseudoeyst in 4, adenoma in 1, Schwannoma in 1 and adrenal cyst in 1.
CONCLUSIONS: We believe that Laparoscopic Adrenalectomy is a safe technique and must be included in the therapeutical alternatives of Urological training. Having found an Adrenal Cancer in an incidental tumour of 4 cms, we keep the 3 cms tumour diameter as cut point for indication of surgery in incidental masses. There is no major difference between the trans or retroperitoneal approach and for this reason its choice is a matter of surgeon's preference and must be tailored to each case.
CONCLUSIONS: Laparoscopic adrenalectomy seems to be the operation of choice in the majority of adrenal lesions. Complications will be reduced considerably by passing learning curve. By increasing experience, larger adrenal masses can be done by laparoscopic approach safely.
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8
THE LAPAROSCOPIC MANAGEMENT OF A P R I M A R Y A D R E N A L MALIGNANT MELANOMA
IMPROVEMENT OF H I S T O P A T H O L O G I C A L CLASSIFICATION OF A D R E N O C O R T I C A L T U M O U R S BY GENETIC DIFFERENTIATION?
Voudoukis T. 1, Liatsikos E. 2, Papathanasiou Z. 3, Repanti M. 4, Sklavou C. s, Filos C. 2, Barbalias G. 2 1University Hospital of Patras, Urology, Patras, Greece, 2University of Patras, School of Medicine, Patras, Greece, 3University Hospital of Patras, Radiology, Patras, Greece, 4St. Andrews General Hospital, Pathology, Patras, Greece, SUniversity Hospital of Patras, Anesthesiology, Patras, Greece I N T R O D U C T I O N & OBJECTIVES: Primary malignant melanoma (PMM) of the adrenal gland describes an exceptionally rare pathological entity, which is encountered in no more than 20 reports in the literature. In this study, we present our experience with the laparoscopic management o f a PMM of the adrenal gland. M A T E R I A L & METHODS: A 42-year-old male presented with a 3-mo history of a mild flank pain, weight loss and anemia. Laboratory investigations and physical examination were not remarkable for any other abnormalities. Abdominal imaging (ultrasound, CT and MR imaging) depicted the presence of a 55"60 m m round, inhomogeneous, not invasive mass located at one of the peduncles of the left adrenal gland. The right adrenal gland was intact. During laparoscopic transperitoneal adrenalectomy, the mass, grossly, proved to be brown-black, presenting a smooth capsule, areas of focal necrosis without infiltrating adjacent anatomic structures. RESULTS: The mass was en bloc removed along with the left adrenal gland and its histopathologic evaluation was consistent with the features of a malignant melanocytic tumour. Meticulous dermatologic and ophthalmologic examinations did not reveal any pigmented, mucosal, cutaneous or ocular lesion. Postoperatively, the patient presented no signs of fever or remarkable blood loss and was discharged on the 3rd day in good clinical condition.
CONCLUSIONS: Laparoscopic adrenalectomy has been rapidly established as a safe and effective treatment method for most adrenal masses. PMM of the adrenal is a rare finding and is a further challenge for the laparoscopist.
European Urology Supplements 4 (2005) No. 3, pp. 4
Junker K. 1, Gruschwitz T. 1, Breza j.2, Wunderlich H?, Schubert J? IKlinikum der Friedrich-Schiller-Universit/it, Dept. of Urology, Jena, Germany, 2University of Bratislava, Dept. of Urology, Bratislava, Slovakia I N T R O D U C T I O N & OBJECTIVES: The majority of adrenal masses are benign adrenocortical adenomas. Patients with functioning mmours are offered surgery routinely. Decision about therapy for patients with non-functioning tumours depends on symptoms and change in tumour size. The minimal size of incidental tumours varied between 3-5 cm. However, up to 10% of carcinomas lie in this range. Therefore, a predictive genetic test discriminating between benign and malignant disease for incidentally detected turnouts would represent a significant advance in the clinical management of patients. In order to define specific genetic alterations of adrenal adenomas and carcinomas, we performed the Comparative Genetic Hybridization on 17 (CGH) adrenal tumours. M A T E R I A L & METHODS: Histological paraffin sections were evaluated by a pathologist. Areas with high amounts of turnout cells were selected. DNA was isolated from these areas and amplified by a modified protocol for DOP-PCR. After labelling of tumour-DNA and normal DNA with biotin-dUTP and digoxigenin-dUTP, respectively. Hybridization and detection were carried out according to standard protocols. RESULTS: Genetic alterations were seen in all carcinomas and in 57% of adenomas. The mean number of alterations was 8.2 (4-12) and 2.0 (0-7) in carcinomas and adenomas, respectively. Alterations detected in adenomas were losses of chromosomes lp, 3p, 4q, 5q, 7q, 8p, 9q, 10q, llp,13q,14,1 8p (each occurred only once). In carcinomas, the following alterations were seen frequently: losses of 1/lp (50%), 3/3p (70%), 4q (30%), 5q (3%), 6/6q (40%), 9p, 9q (30%), l l p (40%), l l q (30%), 13q (40%), 14q (30%), 15q (40%), 18q (70%). Gains of chromosomes did not occur frequently.
CONCLUSIONS: This study clearly showed differences in genetic alterations of adenomas and carcinomas. The data indicate a high grade of genetic changes in carcinomas compared to adenomas. Furthermore, specific chromosomes or chromosomal regions were identified involved in development of carcinomas. Therefore, genetic studies will open the possibility for discrimination between adenomas and carcinomas leading to a better management of patients with adrenal tumour masses in the future.
5 L A P A R O S C O P I C A D R E N A L E C T O M Y IN U R O L O G I C P R A C T I C E , A COMBINED C H I L E A N AND G E R M A N EXPERIENCE
L A P A R O S C O P I C A D R E N A L E C T O M Y ; EXPERIENCE OF 9 YEARS
Guzmfin S. 1, Hatzinger M. 2, Kamp S.2, Velasco A?, Haecker A.2, Gimdnez F. 1, Monteverde E. 1, Jeanneret V.1, Michel M.S.2, Alken R 2
Simforoosh N. Basiri A., Danesh A., Sharifi-Aghdas F., Ziaee S.A.M., Tabibi A., Nadj aft- Semnani M.
~E Universidad Cat61ica, Urology Department, Santiago, Chile, 2University of Mannheim, Urology Department, Mannheim, Germany
Shahid Beheshti University of Med Scie, Urology, Tehran, Iran
INTRODUCTION & OBJECTIVES: Laparoscopic adrenalectomy has become a standard of care in the last ten years. The purpose of this report is to analyze a combined Chilean and German institutional experience in laparoscopic adrenalectomy, with special attention to different approaches (transperituneal or retroperitoneal) as done with preference each centre.
I N T R O D U C T I O N & OBJECTIVES: We performed 45 laparoscopic adrenalectomy from October 1995 until June 2004 in Shahid Labbafinejad Medical Centre, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Hereby we describe our experience.
MATERIAL & METHODS: The clinical and pathological data from 32 patients who underwent Laparoscopic Adrenalectomy between September 1999 and September 2004 were reviewed. Two groups of patients were studied, a group operated in Chile through a transperitoneal approach, and a group operated in Germany mainly through a retroperitoneal approach. Surgery was indicated for all functional masses, and for incidental masses bigger than 3 cms in diameter or that showed change in radiologic follow-up.
M A T E R I A L & METHODS: 44 patients (30 female and 14 male) with mean age of 39.1 years (22-59) were presented. One female patient, known case of Cushing's disease who had failed transsphenoidal hypophysial surgery underwent simultaneous bilateral adrenalectomy. 9 patients were diagnosed incidentally to have adrenal mass. Hypertension was the chief complaint in 25 (57%) cases.
RESULTS: The series is composed of 32 patients, 60% male, 40% female, mean age of 50 years (27-68). Indication was: Incidental Tumour in 78%, 6.2% Cushing Syndrome, 12.5% Hyperaldosteronoma and 3% Pheocromocitoma. A Transperitoneal approach was used in 27 patients, in 5 a Retroperitoneal approach was used, selection was done upon surgeon's preference. Mean operative time was 130 minutes (50-240), and did not correlate with tumour size that ranged from 1 to 15 cms. There was also no significant time difference considering the surgical approach whether trails or retroperitoneal. Conversion rate was 12% (3 cases, 2 to open surgery and 1 to hand-assisted surgery). Mean in hospital stay was 2 days in the Chilean group and 4 in the German group. Pathologic analysis showed in 19 (59.14%) adrenal cortical adenoma, 1 (3.12%) adrenal carcinoma, 2 (6.25%) ganglioneuroma, 4 (12.5%) adrenal epithelial cyst, 2 (6.25%) mielolipoma, 1 (3.12%) supernumerary spleen, 1 (3.12%) inflammatory tumour, and 2 (6.25%) pheoeromocitoma The patient with an adrenal carcinoma had a 4 cms tumour that was an incidental finding in radiol0gieal controls. There was no mortality, with a significant morbidity of 3.12%, 1 patient that had a postoperative hemoperitoneum that needed revision.
RESULTS: Mean of maximum diameter and weight of adrenal mass were 5.7 (2.1-9.5) cm and 54 gm (3-379). Mean operation time for unilateral cases was 189 ± 58 minutes. Perioperative blood transfusion was required in 3 patients. Conversion to open surgery was needed in 5 (11%) and reoperation for hemorrhage was done in 1 case. There was one ileal injury in a patient with history of previous abdominal surgery and dense adhesions which repaired laparoscopically without any postoperative problem. All complications occurred in first 25 cases and there was no major complication in last 19 cases. Pathological diagnosis were pheochromocytoma in 18 (41%), aldosterone producing adenoma (APA) in 14 (31,8%), pseduoeyst in 5 (11.4), myelolipoma in 2, Schwannoma in 1, adrenal cyst in 1 and nodular cortical adrenal hyperplasia in case of bilateral adrenalectomy. Pathological diagnosis in incidentally diagnosis cases were APA in 2 patients, pseudoeyst in 4, adenoma in 1, Schwannoma in 1 and adrenal cyst in 1.
CONCLUSIONS: We believe that Laparoscopic Adrenalectomy is a safe technique and must be included in the therapeutical alternatives of Urological training. Having found an Adrenal Cancer in an incidental tumour of 4 cms, we keep the 3 cms tumour diameter as cut point for indication of surgery in incidental masses. There is no major difference between the trans or retroperitoneal approach and for this reason its choice is a matter of surgeon's preference and must be tailored to each case.
CONCLUSIONS: Laparoscopic adrenalectomy seems to be the operation of choice in the majority of adrenal lesions. Complications will be reduced considerably by passing learning curve. By increasing experience, larger adrenal masses can be done by laparoscopic approach safely.
7
8
THE LAPAROSCOPIC MANAGEMENT OF A P R I M A R Y A D R E N A L MALIGNANT MELANOMA
IMPROVEMENT OF H I S T O P A T H O L O G I C A L CLASSIFICATION OF A D R E N O C O R T I C A L T U M O U R S BY GENETIC DIFFERENTIATION?
Voudoukis T. 1, Liatsikos E. 2, Papathanasiou Z. 3, Repanti M. 4, Sklavou C. s, Filos C. 2, Barbalias G. 2 1University Hospital of Patras, Urology, Patras, Greece, 2University of Patras, School of Medicine, Patras, Greece, 3University Hospital of Patras, Radiology, Patras, Greece, 4St. Andrews General Hospital, Pathology, Patras, Greece, SUniversity Hospital of Patras, Anesthesiology, Patras, Greece I N T R O D U C T I O N & OBJECTIVES: Primary malignant melanoma (PMM) of the adrenal gland describes an exceptionally rare pathological entity, which is encountered in no more than 20 reports in the literature. In this study, we present our experience with the laparoscopic management o f a PMM of the adrenal gland. M A T E R I A L & METHODS: A 42-year-old male presented with a 3-mo history of a mild flank pain, weight loss and anemia. Laboratory investigations and physical examination were not remarkable for any other abnormalities. Abdominal imaging (ultrasound, CT and MR imaging) depicted the presence of a 55"60 m m round, inhomogeneous, not invasive mass located at one of the peduncles of the left adrenal gland. The right adrenal gland was intact. During laparoscopic transperitoneal adrenalectomy, the mass, grossly, proved to be brown-black, presenting a smooth capsule, areas of focal necrosis without infiltrating adjacent anatomic structures. RESULTS: The mass was en bloc removed along with the left adrenal gland and its histopathologic evaluation was consistent with the features of a malignant melanocytic tumour. Meticulous dermatologic and ophthalmologic examinations did not reveal any pigmented, mucosal, cutaneous or ocular lesion. Postoperatively, the patient presented no signs of fever or remarkable blood loss and was discharged on the 3rd day in good clinical condition.
CONCLUSIONS: Laparoscopic adrenalectomy has been rapidly established as a safe and effective treatment method for most adrenal masses. PMM of the adrenal is a rare finding and is a further challenge for the laparoscopist.
European Urology Supplements 4 (2005) No. 3, pp. 4
Junker K. 1, Gruschwitz T. 1, Breza j.2, Wunderlich H?, Schubert J? IKlinikum der Friedrich-Schiller-Universit/it, Dept. of Urology, Jena, Germany, 2University of Bratislava, Dept. of Urology, Bratislava, Slovakia I N T R O D U C T I O N & OBJECTIVES: The majority of adrenal masses are benign adrenocortical adenomas. Patients with functioning mmours are offered surgery routinely. Decision about therapy for patients with non-functioning tumours depends on symptoms and change in tumour size. The minimal size of incidental tumours varied between 3-5 cm. However, up to 10% of carcinomas lie in this range. Therefore, a predictive genetic test discriminating between benign and malignant disease for incidentally detected turnouts would represent a significant advance in the clinical management of patients. In order to define specific genetic alterations of adrenal adenomas and carcinomas, we performed the Comparative Genetic Hybridization on 17 (CGH) adrenal tumours. M A T E R I A L & METHODS: Histological paraffin sections were evaluated by a pathologist. Areas with high amounts of turnout cells were selected. DNA was isolated from these areas and amplified by a modified protocol for DOP-PCR. After labelling of tumour-DNA and normal DNA with biotin-dUTP and digoxigenin-dUTP, respectively. Hybridization and detection were carried out according to standard protocols. RESULTS: Genetic alterations were seen in all carcinomas and in 57% of adenomas. The mean number of alterations was 8.2 (4-12) and 2.0 (0-7) in carcinomas and adenomas, respectively. Alterations detected in adenomas were losses of chromosomes lp, 3p, 4q, 5q, 7q, 8p, 9q, 10q, llp,13q,14,1 8p (each occurred only once). In carcinomas, the following alterations were seen frequently: losses of 1/lp (50%), 3/3p (70%), 4q (30%), 5q (3%), 6/6q (40%), 9p, 9q (30%), l l p (40%), l l q (30%), 13q (40%), 14q (30%), 15q (40%), 18q (70%). Gains of chromosomes did not occur frequently.
CONCLUSIONS: This study clearly showed differences in genetic alterations of adenomas and carcinomas. The data indicate a high grade of genetic changes in carcinomas compared to adenomas. Furthermore, specific chromosomes or chromosomal regions were identified involved in development of carcinomas. Therefore, genetic studies will open the possibility for discrimination between adenomas and carcinomas leading to a better management of patients with adrenal tumour masses in the future.