Minimally invasive surgery may be effective for Cushing’s: Study
Procedure for partial adrenalectomy led to fewer complications, less recurrence
Partial adrenalectomy, or the removal of only a portion of the adrenal gland containing a tumor instead of the entire gland, using a minimally invasive procedure is safe and feasible in people with Cushing’s syndrome and other conditions, according to a study in Germany.
The procedure, called posterior retroperitoneoscopic partial adrenalectomy, involves accessing the adrenal glands from the back of the body through small incisions in the retroperitoneal space, or the area behind the abdominal cavity. The surgery was associated with a low rate of complications and disease recurrence, according to researchers.
“This makes it the preferred operation in cases of bilateral disease [on both adrenal glands] and for selected patients with benign [diseases],” they wrote.
The study, “Partial adrenalectomy by the posterior retroperitoneoscopic approach: A single institution series of 766 consecutive procedures,” was published in the World Journal of Surgery.
Cushing’s syndrome is a broad term for conditions characterized by high levels of cortisol, a steroid hormone normally produced by the adrenal glands. Cushing’s disease, one of its most common forms, is caused by a tumor in the brain’s pituitary gland, which produces excessive amounts of adrenocorticotropic hormone (ACTH), a signaling molecule that promotes cortisol production.
Less commonly, Cushing’s arises due to a tumor in the adrenal glands, independently of ACTH production. Surgery to remove the adrenal glands, a procedure called adrenalectomy, is a common treatment used in such cases. This type of surgery encompasses both partial adrenalectomy, in which only the affected tissue is removed to preserve adrenal function, and total adrenalectomy, in which the entire gland is removed.
Partial adrenalectomy may lead to better outcomes for Cushing’s patients
Previous studies indicated partial adrenalectomy could be associated with better outcomes for Cushing’s patients than total adrenalectomy.
In the study, a team of researchers from the Kliniken Essen-Mitte, academic teaching hospital of the University of Duisburg-Essen in Germany, analyzed the long-term outcomes of patients who underwent partial adrenalectomy using the posterior retroperitoneoscopic procedure.
A total of 709 partial adrenalectomies were performed in 697 patients for several conditions from January 2010 to December 2023 at the researchers’ institution. These conditions included Cushing’s syndrome (102 patients), pheochromocytoma (239 patients), nonfunctioning tumors (66 patients), Conn’s syndrome (225 patients), adrenal metastases (38 patients), and others (27 patients).
Of note, pheochromocytoma is a rare type of adrenal tumor; nonfunctioning tumors are those that don’t produce hormones and are usually benign; Conn’s syndrome is a condition that arises when the adrenal glands produce excessive amounts of the hormone aldosterone; and adrenal metastases refers to the spread of cancer from other parts of the body to the adrenal glands.
Overall, 562 patients, including 69 with Cushing’s, had unilateral disease (one adrenal gland affected), while 135 patients, including 33 with Cushing’s, had bilateral disease (both adrenal glands affected).
The mean operating time for unilateral or bilateral adrenalectomies performed simultaneously by two surgical teams was 39.2 minutes, and 92 minutes for the bilateral procedure when performed by a single surgical team. For Cushing’s patients, the mean operating time was 36.3 minutes.
Minor surgery-related complications were observed in 1.5% of the patients, and included hematoma, relaxation or abnormal sensation in the flank area, and a type of hernia associated with the incision.
All 55 patients with clinical Cushing’s received corticosteroids post-surgery
Among the 55 patients with overt clinical signs of Cushing’s, all received treatment with corticosteroids after surgery, regardless of whether the operation had involved one adrenal gland (37 patients) or both glands (18 patients).
Long-term follow-up data was available for about a third of the patients, including 46 people with Cushing’s. At the last evaluation, 17 of these patients (37%) were still on corticosteroid therapy, and about half of them (53%) had undergone bilateral surgery. In two patients, the disease had returned.
Among patients without Cushing’s, about a quarter of those who underwent bilateral surgery required corticosteroid replacement therapy. None of those who underwent unilateral surgery required corticosteroid therapy.
The researchers noted that although data about partial adrenalectomy in people with Cushing’s is limited, some studies suggest patients who undergo partial surgery require corticosteroid supplementation for shorter periods, compared with those undergoing total gland removal.
They also noted that because follow-up data was only available for a relatively small proportion of the patients in the study, “the recurrence rate and the need for [corticosteroid replacement therapy] could be underestimated.”
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