Algoritmo decisionale e terapeutico

negli incidentalomi surrenalici

Algoritmo decisionale e terapeutico

negli incidentalomi surrenalici

Micaela PiccoliMicaela Piccoli

Divisione di Chirurgia Generale(Primario: Prof. Gianluigi Melotti)

Ospedale Sant’AgostinoModena, Italia

Scuola Speciale ACOI

di Chirurgia laparoscopica e mini-invasiva

(Direttore: Prof. Gianluigi Melotti)

www.acoi.it

XXIV CONGRESSO NAZIONALE ACOI25/28 Maggio 2005 - Montecatini

Terme

NIH Consensus and State-of-the Science Statements

2002, Feb 4-6;9(2);1-25

NIH Consensus and State-of-the Science Statements

2002, Feb 4-6;9(2);1-25

Management of the ClinicallyManagement of the Clinically Inapparent Adrenal MassInapparent Adrenal Mass

(“Incidentaloma”)(“Incidentaloma”)

Management of the ClinicallyManagement of the Clinically Inapparent Adrenal MassInapparent Adrenal Mass

(“Incidentaloma”)(“Incidentaloma”)

IncidentalomaIncidentaloma

• Ormonalmente attivo o non funzionante ?• Benigno o maligno ?

• Se funzionante: surrenalectomia• Se non funzionante:

– > 6 cm surrenalectomia; – < 4 cm (senza sospetti nell’imaging) monitoraggio– 4-6 cm ?

Quale intervento?Controindicazioni all’appproccio laparoscopico?

Quale intervento?Controindicazioni all’appproccio laparoscopico?

• Invasive adrenal carcinoma• Malignant pheochromocytoma

Size

Infiltrating mass

• Laparoscopic adrenalectomy is also effective and safe for large lesions….The risk of encountering an incidental adrenal cortical cancer is significantly increased for large lesions, and therefore, in these cases, additional attention is required to observe oncologic surgical principles

Urology 2002 Nov 60(5):801-5. Case-history :125 patients

Laparoscopic adrenalectomyThe size of the mass

Laparoscopic adrenalectomyThe size of the mass

Laparoscopic adrenalectomyThe size of the mass

Laparoscopic adrenalectomyThe size of the mass

Does tumor eterogeneity limit the use of the Weiss criteria in the evoluation

of adrenocortical tumours ?

Does tumor eterogeneity limit the use of the Weiss criteria in the evoluation

of adrenocortical tumours ?

• Adrenal incidentalomas larger than 6 cm with imaging features such as intratumoral necrosis suggestive of malignancy, should be manged as potential cancers independent of the so called Weiss criteria.

J Endocrinol Invest 2004 Jun;27 (6):565-9

AdrenalectomyAdrenalectomyIndications to laparoscopic approachIndications to laparoscopic approach

PheochromocytomaConn's adenomaNonfunctioning adenomaCarcinomaCushing's adenomaCushing's syndromeAngioMyolipomaMetastasisGanglioneuromaCyst

103 patients (3/95 - 8/3/05)

20

14

2965

87

7363 women, 40 menMean age: 49,8 years (range: 22-76)

4

Department of General Surgery

(Chief: Prof. Gianluigi Melotti)

Sant’Agostino Hospital

Modena, Italy

1995-200321 incidentalomi

15 femmine6 maschi

Età media 51,7(20-72 aa)

17 controlli3 dolori addominali

1 nefrolitiasi

Follow up in 7 casi(min 2 max 12 aa)

12dx 9 sin

7 adenomi 1 cisti vascolare

3 feocromocitomi2 pseudocisti

2 ganglioneuromi1 iperplasia nodulare

1 linfangioma cavernoso3 mielolipomi

1 metastasi

0

1

2

3

4

5

6

7

8

3,1-4 4,1-5 5,1-6 6,1-7 7,1-8 >10

n.casi

cm