Large Adrenal lesions - Management at a tertiary centre in Greece

Introduction and Objective : “Large adrenal lesions” are considered tumours with a size varying between 5cm to 10 cm, with a general consensus measuring approximately 6 cm. Adrenal lesions are common with adrenalectomy being the third commonest endocrine procedure. However, large adrenal lesions are rare with an incidence ranging from 8.6% to 38.6% of adrenal tumours. There is evidence that the risk of malignancy increases with a tumour size of more than 4cm. With advances in modern imaging and rapidly aging population, the presentation of an incidentally found adrenal mass has become an increasingly common scenario for endocrine surgeons and Urologists. Resection of large adrenal lesions could be challenging, especially when it is performed laparoscopically. Our aim is to present the surgical outcomes of our patients operated for large adrenal lesions measuring more than 6cm in size and to validate the role of laparoscopic surgery in the management of these tumours. Methods : This is a retrospective study of patients operated for an adrenal lesion, measuring more than 6cm, in Aretaieio university hospital, between July 2008 and April 2018. Patients underwent open or laparascopic procedure. The preoperative diagnosis, operative details, complications, length of hospital stay, morbidity and follow-up were recorded and tabulated. Results : 45 patients had lesions over 6cm (47 lesions) with mean size 8.38cm. Out of these 45 patients 25 were female patients, and 20 males, with mean age of 58.2 years. 31.9% of the lesions were found to be malignant with an average size of 11.33cm and the rest were benign with an average size of 7.65cm (pvalue=0.01). Most of the cases operated for an adrenal mass were for Pheochromocytoma (27.7%) that had mean size of 7.5cm, followed by Adenocortical carcinomas (23.4%) and Adenocortical adenomas (21.3%) with mean size of 12.5cm and 6.78cm respectively. 28 out of 47 cases (59.6%) had open surgery, while the rest underwent laparoscopic approach; 13 (25.7%) transabdominal and 6 (12.8%) posterior retroperitoneal approach. The majority of the malignant cases (94%) had open surgery. Although no differences were noticed in the complication rates between open and laparoscopic surgery, there was a statistical significant reduction in the duration of the hospital stay, in the patients treated laparoscopically (mean stay 3.7d over 9.5d, pvalue<0.01). Conclusion : Laparoscopic resection of large adrenal lesions could be challenging but if expertise is available could be effectively performed. Risks and complications are reduced when the surgical approach is tailored for each patient.