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Zorluk: ZorBreast and Endocrine Surgery

Match each patient's clinical presentation and imaging findings of an adrenal mass with the most appropriate definitive surgical and perioperative management plan.

  • A 42-year-old man with treatment-resistant hypertension and muscle cramps; labs show potassium 2.8 mEq/L, low plasma renin activity, and high plasma aldosterone. Computed tomography (CT) shows a 2.5-cm unilateral adrenal nodule.Correction of hypokalemia with an aldosterone antagonist, followed by laparoscopic adrenalectomy
  • A 38-year-old woman with central weight gain, facial plethora, and easy bruising; labs show elevated 24-hour urine free cortisol and undetectable adrenocorticotropic hormone (ACTH). CT shows a 3.5-cm adrenal mass.Laparoscopic adrenalectomy with perioperative stress-dose glucocorticoids and subsequent slow taper
  • A 45-year-old man with paroxysmal palpitations, sweating, and severe headaches; 24-hour urine fractionated metanephrines are markedly elevated. CT shows a 4.5-cm right adrenal mass.Alpha-adrenergic blockade followed by beta-adrenergic blockade, then laparoscopic adrenalectomy
  • A 52-year-old woman with rapidly progressive hirsutism, voice deepening, and abdominal pain; imaging reveals a 7.5-cm heterogeneous adrenal mass with irregular margins.Open transabdominal adrenalectomy with wide margins; avoid minimally invasive approach

Cevap

Primary hyperaldosteronism is matched with aldosterone antagonist preparation and laparoscopic surgery. Cushing adenoma is matched with laparoscopic surgery and stress-dose steroids. Pheochromocytoma is matched with alpha then beta blockade and laparoscopic surgery. Suspected adrenocortical carcinoma is matched with open transabdominal adrenalectomy.
The surgical management of adrenal masses is highly specific to their functional status and oncologic risk. Benign functioning tumors require targeted perioperative medical management and minimally invasive resection, whereas highly suspicious malignant tumors demand open oncologic resection.

Adım Adım Çözüm

1
Diagnose the specific endocrine hypersecretory syndrome or suspicion of malignancy for each adrenal mass presentation.
The presentations represent primary hyperaldosteronism, ACTH-independent Cushing syndrome, pheochromocytoma, and adrenocortical carcinoma (ACC), respectively.
Accurate functional and oncologic diagnosis dictates both the required preoperative medical blockade and the appropriate surgical approach.
2
Determine the necessary preoperative medical optimization for each functioning tumor.
Primary hyperaldosteronism requires potassium correction and blood pressure control; pheochromocytoma requires alpha-blockade followed by beta-blockade.
Appropriate preparation prevents severe intraoperative complications such as hemodynamic instability, arrhythmias, or severe hypokalemia.
3
Determine the postoperative medical management needs based on the functional status of the tumor.
Cushing adenoma requires administration of stress-dose steroids postoperatively.
The contralateral adrenal gland is suppressed by prolonged hypercortisolism, putting the patient at immediate risk of secondary adrenal insufficiency once the adenoma is removed.
4
Select the appropriate surgical approach based on tumor size and suspicion of malignancy.
ACC requires an open approach; the benign functional adenomas (<6 cm) can be managed laparoscopically.
Laparoscopic adrenalectomy for ACC has an unacceptably high risk of capsular disruption, peritoneal seeding, and incomplete resection.

Anahtar Kavram

Preoperative optimization, postoperative glucocorticoid management, and the selection of surgical approach (open vs. laparoscopic) for various functional and malignant adrenal tumors.
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Breast and Endocrine Surgery

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