New Adrenalectomy Guidelines Cover Surgery, Multispecialty Care

New adrenalectomy guidelines from the American Association of Endocrine Surgeons are aimed at assisting both specialist and general surgeons with perioperative adrenal care, including guidance on management of adrenal incidentalomas.

Published online August 17 in JAMA Surgery, the guidelines offer 26 separate recommendations under seven headings: incidentalomas/myelolipomas/cysts, primary aldosteronism, hypercortisolism, adrenocortical carcinoma, metastasis to the adrenal gland, pheochromocytoma/paraganglioma, and technical aspects.

"Adrenal pathology is something that every surgeon is going to see at some point in their practice. [It is] important to have up-to-date and evidence-based guidelines to reference and guide appropriate management of these patients," first author Linwah Yip, MD, of the Division of Endocrine Surgery at the University of Pittsburgh, Pennsylvania, said in a JAMA podcast.

Corresponding author Nancy D. Perrier, MD, of the Department of Surgical Oncology at MD Anderson Cancer Center, Houston, added: "We recognize the importance of incorporating advances in the technical skill and the understanding of adrenal disease, and we recognized that there was a paucity of evidence-based data to guide the contemporary questions that exist regarding adrenal resection. So we aimed to put together recommendations for guidance on effective therapeutic treatments for management of patients around the entire adrenal operation. [There was really a need] because this has not been previously performed."

Its intended audience extends beyond surgeons to include endocrinologists, oncologists, radiologists, radiation oncologists, internists, pathologists, and patients with adrenal tumors, the authors write.

In an accompanying editorial, Tracy S. Wang, MD, of the Department of Surgery, Medical College of Wisconsin, Milwaukee, and Carmen C. Solórzano, MD, of the Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, write that the new guidelines "represent an important must-read document for surgeons in North and South America and worldwide. They incorporate new and old concepts while carefully analyzing the most currently available data to help surgeons and other clinicians navigate the surgical management of adrenal neoplasms." The authors, they say, "are to be congratulated for this comprehensive update."

Incidentaloma Management: Still a bit of Controversy?

The document advises that patients with an adrenal incidentaloma — that is, a lesion identified on imaging studies performed for other reasons — of 1 cm or larger on cross-sectional imaging should undergo further imaging characterization and biochemical testing for autonomous cortisol secretion. Adrenal protocol CT should be used to stratify malignancy risk and concern for pheochromocytoma.

"More than 75% of adrenal incidentalomas are benign adenomas and are nonfunctional; however, evaluation for hormone excess and potential malignancy are of critical importance, as these typically require surgical excision," Yip and colleagues write.

For nonfunctional nodules of less than 4 cm with benign imaging characteristics and tumor density less than 10 Hounsfield units on noncontrast CT, the document advises against routine scheduled follow-up "because the risk of malignancy is very low."

The editorialists add a caveat, noting, "Multidisciplinary care is particularly important in determining the appropriate follow-up, both radiographic and biochemical, in patients who have nonfunctional adrenal tumors with benign imaging characteristics."

They point out that the level of evidence for the recommendation against routine screening in that group is "low quality" and "follow-up remains a source of controversy. We suggest that the approach to follow-up may be guided by specific patient and/or tumor characteristics, and a multidisciplinary discussion may allow for better identification of patients for whom more close surveillance may be appropriate."

The document does say that for nodules 1-4 cm with indeterminate imaging characteristics, at least one repeated image at 6-12 months is advised to confirm stability. Since autonomous cortisol secretion is the most common hormonal excess to develop during surveillance, the document suggests re-evaluation at 2- to 5-year intervals.

Perrier commented, "In other words, the onus is not there on the surgeon, for a lesion that meets all those characteristics in a patient where it's incidentally identified, they don't need to track those patients long-term. I think that's going to be important for many surgeons because of the vast number of incidentalomas that appear on routine CTs...The recommendation actually has several more bullets to it that talk about if you were to have a specific hormone that you were to test in the future, the surveillance data suggest it's going to be autonomous cortisol secretion that's going to happen in the future, so if you're going to recheck, we strongly recommend that."

Guidelines Also Cover Surgical Aspects, Emphasize Multidisciplinary Care

Other recommendations include:

When unilateral disease is present, laparoscopic adrenalectomy is recommended for patients with primary aldosteronism or autonomous cortisol secretion.
Following unilateral adrenalectomy, empirical postoperative glucocorticoid replacement therapy is recommended for all patients with Cushing syndrome. For those with mild autonomous cortisol secretion, postoperative day 1 morning cortisol or corticotropin stimulation testing could be used to determine the need for glucocorticoid replacement therapy.
Patients with clinical and radiographic findings consistent with adrenocortical carcinoma should be treated at high-volume multidisciplinary centers to optimize outcomes.
Regardless of operative approach, the recommendation is for an en bloc radical resection with an intact capsule to microscopically negative (R0) margins because of improved survival.
Although open resection is preferred when ACC is suspected, the choice of operative approach should be based on the certainty of a complete R0 resection without tumor disruption.
Selective or nonselective alpha-blockade can be used to safely prepare patients for surgical resection of paraganglioma/pheochromocytoma for at least 7 days in advance.
When patient and tumor variables are appropriate, minimally invasive adrenalectomy is recommended over open adrenalectomy because of improved perioperative morbidity.
Minimally invasive adrenalectomy can be achieved either via a retroperitoneal or transperitoneal approach depending on surgeon expertise, as well as tumor and patient characteristics.

Wang and Solórzano write in their editorial, "We agree that for most patients who undergo adrenalectomy, a minimally invasive approach is appropriate and preferred, whether transabdominal or posterior retroperitoneal...The authors note that while robotic adrenalectomy is safe and feasible, there is a reported increased cost and lack of prospective comparative studies to analyze benefits, compared with laparoscopic approaches. While there are initial costs to investment in the robotic platform, careful team planning, and thoughtful consideration of instrument use, as well as surgeon awareness of associated costs, can lower the cost per individual adrenalectomy."

And, they add, "Most importantly, we would emphasize the importance of offering all surgical approaches (open/robotic/laparoscopic, posterior retroperitoneal, and transabdominal) to patients, guided by individual patient and tumor characteristics, at high-volume centers."

Yip and Perrier have no disclosures. Disclosures for the other authors are listed with the guidelines. Wang and Solórzano have no disclosures.

JAMA Surg. Published online August 17, 2022. Abstract, Editorial

Miriam E. Tucker is a freelance journalist based in the Washington, DC, area. She is a regular contributor to Medscape, with other work appearing in The Washington Post, NPR's Shots blog, and Diabetes Forecast magazine. She is on Twitter: @MiriamETucker.

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