Transcript M. Battaglia (Bari)

Dipartimento dell’Emergenza e dei Trapianti d’Organo
Sezione di Urologia e Trapianto di Rene
Università di Bari
La chirurgia del surrene
Pasquale Ditonno
Michele Battaglia
Seminari di Fisiopatologia Chirurgica
Bari – 10-11 Novembre 2011
A SURGICAL HISTORY
1563– Eustachius describes
the anatomy of the adrenal
Gland
1855 – Addison correlates
clinical features of adrenal
disease with pathology
found in autopsies
ROUX in Lausane
MAYO in Rochester
YOUNG
1927
1936
ADRENALECTOMY
POSTERIOR
APPROACH
1991
TRANSABDOMINAL
LAPAROSCOPIC
ADRENALECTOMY
1886 – Frankel describes
pheochromocytoma
1912 – Cushing presents
clinical features of
Hypercortisolism
1955 – Conn describes
hyperaldosteronism
Snow
1.Cagner
2.Mercan
ADRENALECTOMY
ANTERIOR
APPROACH
1992
1.LATERAL TRANSABD.
2.POSTERIOR RETROPER.
LAPAROSCOPIC
Advances during the last fifteen years have completely changed our
understanding of and approach…
In the past the diagnosis was complex, time consuming and, sometimes,
frustating process, especially with regard to localization
Scint.Scan.
US,CT,MR,
Interdisciplinary collaboration
Incidentaloma’s increased incidence
36,6%
58,2%
1986
2010
Indicazioni alla chirurgia
“Surgery of the adrenal gland consists of operative
procedures to ‘correct endocrine abnormalities’ or to ‘treat
malignant disease’.
When medical therapy is ineffective or does not exist for a
particular adrenal disease, surgery becomes necessary.”
IS IT MALIGNANT?
IS IT METASTATIC?
IS IT FUNCTIONAL?
Chow and Blute, Surgery of the adrenal glands, Campbell Urology, 9th Ed
SURRENECTOMIA: LA NOSTRA ESPERIENZA (Gennaio 1978-Ottobre 2011)
386 Surrenectomie
188 dx – 188 sx – 10 Bilaterali
184 M – 202 F – Età media: 54 aa (r: 14-82)
Distribuzione per tipo di accesso
lombotomico: 160
Anteriore: 26
Toraco-addominale: 5
Laparoscopico: 195
Laparoscopic adrenalectomy the “platinum standard”
Cestari et al. Curr Opin Urol. 2005 Mar;15(2):69
Major Causes
Benign Adenoma 50%
Cyst 10%
Myelolipoma 10%
Pheochromocytoma 10%
Metastases 6-30%
Adrenal Cancer 0.01%
The incidental adrenal mass. Am J Med 1996
Posizione: Non sul rene, ma mediale al rene, sottodiaframmatica,
dinanzi al pilastro laterale
Quadrilatero di Albarran
Fegato - Milza
Margine med.
polo super.
del rene
Cava
Aorta
Peduncolo renale
E’ contenuto in una propria loggia, inclusa in quella
renale, senza tuttavia stretti rapporti
Tale loggia e’ separata dal polo superiore del rene da
tessuto fibroadiposo ancorato al diaframma
Vie di accesso al surrene
transperitoneale
• addominale
extraperitoneale
• lombotomica
• toraco-freno-laparotomica
• posteriore
• laparoscopica ( trans- e retroperitoneale)
Approccio laparoscopico: i vantaggi
Soddisfazione
del paziente
Cosmesi
Analgesici
Hospital stay
Recovery Time
Elementi da considerare qualunque sia tipo di accesso
 Tipo di patologia (Carcinoma)
 Sede (mono, bilaterale, ectopica)
Volume della lesione
 Body Mass Index
 Friabilità dell’organo
 Attenta emostasi
 Esperienza del chirurgo



Ampiezza del campo operatorio
Dominio dei vasi
Possibilità di estensione dell’accesso
La chirurgia del surrene
L’approccio chirurgico
Patologia
Patients 1004
Non-Secretory
854 (85%)
Pheochromocytoma
42 (4.2%)
Sub-Clinical Cushings Syndrome
92 (9.2%)
Aldosterone-Producing Adenoma
15(1.6%)
Journal of Clinical Endocrinology & Metabolism 85 (2) 637-644, 2000
L’incidentaloma surrenalico
“ Yes, doctor, the abdominal scan was negative for the
problem you were worried about, but we
found another one of those adrenal masses”
A.I.D.S.
Adrenal incidentaloma discovered serendipitously
Su 87.065 autopsie in 24 studi è riportata una incidenza del 6%.
Nelle ecografie addominali una incidenza dello 0,6-1.3 %
Kloss RT et al. Endocr Rev 1995; 16:460
La probabilità della diagnosi correla con l’età:
0.2 % in soggetti di età tra 20 e 29 aa
7 % in soggetti di età superiore ai 70 aa
Qual è l’approccio diagnostico ottimale?
Non esiste uno specifico algoritmo diagnostico
L’approccio diagnostico si basa su:
esperienza clinica del medico
indagini di laboratorio e di imaging
Young WF, NEJM 2007; 356
Sindrome di Cushing subclinica
Il termine subclinico si riferisce alla presenza di una secrezione autonoma di
cortisolo in pazienti che non presentano i caratteristici segni dell’ipercortisolismo
per un nodulo iperfunzionante capace di sopprimere il surrene controlaterale
senza elevare il cortisolo sierico e determinare la classica sindrome
Se lo stato di soppressione ormonale non viene riconosciuto, dopo la
surrenectomia può comparire una crisi addisoniana
Tuttavia questi pazienti spesso presentano gli effetti della
persistente secrezione endogena di cortisolo:
• ipertensione
• obesità
• diabete mellito
• osteoporosi
Emral R. Endocr J 2003;50:399-408
Sindrome di Cushing subclinica
Strategie terapeutiche
Chirurgia
Pazienti giovani
Pazienti sintomatici
Wait and see
Pazienti anziani
Pazienti asintomatici
FEOCROMOCITOMA
E’ un tumore raro con caratteristiche cliniche peculiari allo stesso
tempo una condizione curabile e potenzialmente letale
Fattori di rischio:
•Rilascio di catecolamine imprevisto ed incontrollabile
•Possibilità di malattia multifocale e comportamento maligno
Per curare la malattia:
•Diagnosi precoce
•Localizzazione precisa
•Appropriata preparazione anestesiologica pre and post-operatoria
•Rimozione chirurgica completa
FEOCROMOCITOMA
Hypertension In Pheochromocytoma
• Paroxysmal in 48%--episodically secreted
• Persistent in 29%-- continually secreted
• Normal in 13%
• Attacks of Headaches (80%)
• Palpitations (64%)
• Diaphoresis (57%)
Symptomatic Triad Of Headache, Sweating, And Tachycardia In
A Hypertensive Patient
Sensitivity 90.9% And Specificity 93.8%
Feocromocitoma clinicamente silente
circa il 5% degli incidentalomi surrenalici
Dosaggio delle metanefrine frazionate e catecolamine nelle urine delle 24 ore
Imaging phenotype
Imaging
Alta densità alla TAC
Elevata vascolarizzazione
Ritardato washout del MC
Alta intensità nelle sequenze
T2-pesate (RMN)
Surrenectomia per Feocromocitoma
1959-2011
Bambini
Adulti
Totale
Pz
12
101
113
Sede surrenalica
Sede extra-surr.
Bilaterale
Maligni
Approccio Transperitoneale
Approccio lombotomico
Laparoscopia (dal 2000)
100
8
6
16
53
47
13
Adrenal carcinoma
Rare tumor (0.5-2 case per million)
An extraordinarily aggressive malignancy with an overall poor
prognosis
Despite aggressive surgical therapy, the actuarial 5-year survival
for patients who undergo complete resection ranges 23% to 48%
Incomplete resection (including removal of adjacent, involved
organs) is associated with a median survival of less than 1 year
Dackiw AP, World J Surg 2001;25:914–926
The Mayo Clinic Study
• 342 Patients With Adrenal Incidentaloma
Retrospectively Evaluated
• Tumor Diameter Averaged 2.5 cm
• Most Malignant Tumors Measured > 5 cm
• Removing All Tumors > 4 cm Would Have
Removed Eight Benign Tumors For Every Carcinoma
Incidentally discovered adrenal tumors: an institutional perspective.
Herrera MF; Grant CS; van HeerdenJA; Sheedy PF; Ilstrup DM. Surgery 1991
Dec;110(6):1014-21
Mass
• Masses > 6 cm Usually Are Treated Surgically
• Masses < 4 cm Are Generally Monitored
• Masses Between 4 And 6 cm:
Criteria Other Than Size Should Be Considered In Making The
Decision To Monitor Or Proceed To Surgery
• Experienced investigators now recommend excision of all
tumors >4 cm
National Institutes Of Health
Management Of The Clinically Inapparent Adrenal Mass (Incidentaloma) 2002
Assessment del potenziale maligno
In uno studio condotto su 2005 pazienti con incidentaloma
surrenalico un carcinoma era presente nel 4,7% dei soggetti e il
2,5% risultava affetto da malattia metastatica
Young WF, Endocrinol Metab CNA 2000; 29:159
Dimensioni
Imaging phenotype
Forma irregolare
Densità mista alla TAC
Elevata vascolarizzazione
Ritardato washout del MC
Alta intensità nelle sequenze
T2-pesate (RMN)
>4 cm 90% sensibilità
Bassa specificità
Distribuzione delle neoplasie maligne in rapporto alle dimensioni
300
386 Surrenectomie
250
200
19 Malignancy
150
N° cases
100
50
-
Diametro (cm)
0-4
4-8
8-12
> 12
An incidentally discovered primary Adrenal Carcinoma
Applicability of laparoscopy, with the possibility of tumor fracture
or inadequate resection of adjacent organs, has been questioned
Initial case reports: early postop development of carcinomatosis in all 5
pts with an incidentally discovered primary AC undergone laparoscopy
for a presumed benign adrenal mass (Conn’s [2]; Cushing’s [2]; virilizing
tumor[1]).
3 of 5 suffered local recurrence, and 1 port-site recurrence, after 4-14
months after laparoscopy
Ushiyama T, J Urol 1997;157:2239.
Hofle G, Horm Res 1998;50:237–241.
Hamoir E, Ann Chir 1998;52:364–368.
Deckers S, Horm Res 1999; 52:97–100.
Foxius A, Surg Endosc 1999;13:715–717.
When enthusiasm for laparoscopy turns to tragedy
MD Anderson Cancer Center:
at a median follow up of 28 months, comparison of recurrence rates for laparoscopic
and open resection of AC.
Open group:
86% of patients recurred with 62% dying of mets and 24% alive with disease. Of
these, 35% with local rec, 8% carcinomatosis, and remaining with mets.
Lap group:
6 pts 100% recurred, with higher percentage (83%) carcinomatosis
At a follow up of 15 months, 66% pts died from mets, and 33% alive with disease
Open group: 6 pts with tumors <6 cm 4 of 6 were disease-free at 21 months
Lap group: 5 pts with tumors <6 cm developed local rec, distant, and/or peritoneal
mets
In 2 of 6 cases, tumor fracture, rupture, or uncontrolled hemorrhage reported
Gonzalez RJ, Laparoscopic resection of adrenal cortical carcinoma: a
cautionary note. Surgery 2005;138:1078–1086.
Gill recently described 31 pts undergone lap adrenalectomy for
malignancy; 26 isolated adrenal mets, 6 primary incidental adrenal ca,
and 1 malignant pheo.
The overall local recurrence rate was 23%.
5 of 26 (19%) patients with adrenal mets
2 of 6 (33%) with adrenal ca.
Patients with local rec also recurred at other (systemic) sites
Pts with local rec had a lower 3-year survival than pts without local
recurrence (17% vs 66%, P 0.016).
Overall 5-year actuarial survival was 40% at a median follow up of 26
months.
Moinzadeh A, Gill IS. J Urol 2005;173:519–525.
A contemporary review of the literature between 1998 to 2004 reveals
25 cases of AC resected laparoscopically
Local recurrence and/or intraperitoneal dissemination occurred in
10 of 25 (40%) pts
The disease-free interval averaged 34.1 months.
Henry JF, World J Surg 2002;26:1043–1047.
Prager G, Arch Surg 2004;139:46–4961. Zeh HJ 3rd, Udelsman R.Ann
Surg Oncol 2003;10:1012–1017.
Suzuki K. Biomed Pharmacother 2002; 56(suppl):139s-144s.
Kebebew E, Arch Surg 2002;137:948–951.
Belldegrun A, Surg Gynecol Obstet 1986;163:203–208.
Valeri A, Surg Endosc 2002;16:1274–1279.
Despite arguments in favor of applying
minimally invasive approaches
to the majority of adrenal lesions
the laparoscopic resection of primary adrenal
malignancies
remains controversial.
Gonzalez RJ, Surgery 2005;138:1078–1086.
Adrenal Metastasis
Adrenal glands are common sites for mets in a number of primary
cancers, but an isolated metastasis is rare
Resection of isolated adrenal mets of melanoma, lung, kidney, colon,
and breast cancer may improve survival
In series of open adrenalectomy for mets, median survival of 30 months
vs historical survival of 6-8 months without resection
Higashiyama M, Int Surg1994;79:124–129
Adrenalectomy for mets from RCC are associated with the most
favorable results
Lo CY, Br J Surg 1996;83:528–53
Recognition that most malignancies metastasize to the medullary portion,
rather than cortex, rarely penetrate the capsule of the gland
laparoscopic resection less likely to result in tumor fracture,which
predispose to local recurrence or intraperitoneal dissemination
To date, 8 series totaling 98 patients have reported the use of lap
adrenalectomy for mets with no port-site recurrences and only 1 patient
(1%) developing peritoneal dissemination
DFS ranged from 42% to 91% over a mean followup interval
of 8 to 26 months
Greene FL, CA Cancer J Clin 2007;57:130–146
Diverse considerazioni fanno tendere verso una
aggressione laparoscopica nelle metastasi surrenaliche
 Aumentata esperienza del chirurgo
 Migliore visione
 Immediato controllo dei vasi
 Possibilità di esplorare la cavità peritoneale per eventuali
metastasi
 Completo controllo del tumore primitivo
 Metastasi isolata al surrene
 Possibilità di resezione completa del surrene interessato
Chirurgia laparoscopica “organ sparing”
 Accurata emostasi (coagulazione bipolare, colla di fibrina,
EndoGIA, bisturi ad ultrasuoni)
 Indicazioni:
Piccoli Adenomi
Sindrome di Cushing
Feocromocitoma bilaterale
Conclusioni
Migliore accuratezza delle tecniche diagnostiche
Incremento incidentalomi
Neoplasie maligne anche in piccole masse
La chirurgia rimane il gold standard nella cura delle masse
surrenaliche ma con:
minori costi di degenza
migliori risultati estetici
minore morbidita’
minori tempi operatori
sostituendo l’ approccio chirurgico tradizionale con quello
laparoscopico
L’approccio multidisciplinare permette di ottenere i migliori risultati