Large Adrenal Lesion Series in a Tertiary Care Center in Northern India: Diagnostic and Operative Challenges
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ORIGINAL ARTICLE
Large Adrenal Lesion Series in a Tertiary Care Center in Northern India: Diagnostic and Operative Challenges Kushagra Gaurav 1 & Pooja Ramakant 1 Anand K. Mishra 1
&
M. Shreyamsa 1 & Sasi Mouli 1 & Kul Ranjan Singh 1 & Chanchal Rana 2 &
Received: 11 December 2018 / Accepted: 30 May 2020 # Indian Association of Surgical Oncology 2020
Abstract Large adrenal tumors pose varied challenges to surgeons in terms of diagnosis, planning surgical approach, and also intraoperative difficulties in resection. The aim of this study is to discuss challenges in the management of large and difficult adrenal lesions. A retrospective analysis was done on data of all patients with large adrenal lesions/paragangliomas managed from 1 June 2016 to 30 August 2018. Forty-eight patients with adrenal lesions underwent treatment in 2 years duration. Pain in the abdomen was the most common presentation. Mean age was 34.4 years (range 2–60), female to male (23:25) and right to left side to bilateral tumor 30:16:2. Thirty-one (64.6%) patients had large adrenal masses (size > 6 cm). Surgical approaches included open transperitoneal adrenalectomy (n = 20) and laparoscopic transperitoneal (n = 9 and 2 others had conversion to open procedure). Challenges faced are described in the table below: Tumor Teratoma Myelolipoma with bleeding Large right ACC with renal involvement Large left ACC Neuroblastoma
Difficulties handled Large calcified and retrocaval cystic areas difficult to resect, extensive liver mobilization. All adjacent planes destroyed by contained hematoma. Decision to embolize and then operate or directly operate was difficult. Kidney pushed up and out. Splenomegaly hampered dissection. Large tumor mass indenting and displacing IVC, infiltrating liver and kidney. It was downstaged by chemotherapy and then resected.
Malignant left pheochromocytoma Large extensively infiltrated left adrenal mass led to difficult dissection in posterior and medial planes close to great vessels. ACC with Cushing’s Immunocompromised state, poor lung capacity. ACC For IVC + right atrium thrombus with distant metastases given EDP-M regimen, disease stable for 3 months, then progressed. Ganglioneuroma Para-spinal thoracic mass, on CECT? abdominal mass Right side adrenal lesions Hepatomegaly hampering planes of dissection in laparoscopic surgery
There were no major peri-operative morbidities, but two patients died in perioperative period. Large adrenal tumors pose a challenge in surgical planning, approach, and resection and need careful planning and multidisciplinary team approach to have the best outcomes. Keywords Large adrenal lesions . Difficult adrenal surgeries . Giant adrenal masses . Adrenal malignancies
* Pooja Ramakant [email protected] 1
Endocrine Surgery Department, King Georges’ Medical University, Lucknow, Uttar Pradesh, India
2
Pathology Department, King Georges’ Medical University, Lucknow, Uttar Pradesh, India
Introduction Large adrenal lesions (LALs) are defined based on size > 6 cm. LALs pose challenges in dia
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