A New Insight for the Treatment of Primary Macronodular Adrenal Hyperplasia (PMAH): Adrenal Sparing Surgery

Presentation Number: OR04-3
Date of Presentation: April 1st, 2017

Vânia Balderrama Brondani*1, Fabio Y. Tanno2, Victor Srougi3, Madson Q. Almeida4, Carlos Buchpiegel5, Miguel Srougi6, Maria Claudia N Zerbini2, Berenice B Mendonca7, Jose Luiz Chambo8 and Maria Candida B V Fragoso9
1Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, BRAZIL, 2Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 3Sao Paulo University, Sao Paulo, Brazil, 4Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulol, 5Hospital das Clinicas da FMUSP, Sao Paulo, Brazil, 6Hospital das Clinicas, Brazil, 7Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil, 8Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 9Hospital das Clínicas & Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil

Abstract

Introduction: Partial Adrenalectomy (PA) has changed the treatment of patients affected by bilateral adrenal disorders. Currently the evidences regarding the use of PA to treat PMAH are limited 1-3.To date, outcomes of this surgical treatment on hypercortisolism control are not known. In order to overcome the hormonal replacement caveats while minimizing the risks of hypercortisolism relapse, we performed a series of simultaneous total adrenalectomy of largest adrenal gland and partial contra-lateral adrenalectomy (adrenal sparing surgery) to treat patients with PMAH. Methods: Ten patients according to hormonal workup and radiological imaging findings were diagnosed with PMAH and were treated surgically with adrenal sparing surgery. Histological analysis confirmed PMAH in all cases. Primary endpoint was hypercortisolism remission without adrenal insufficiency, considered when patients had physiologic cortisol levels (5-25 μg/L) without hormonal reposition. Adrenal insufficiency and latent adrenal insufficiency were defined when oral hydrocortisone reposition was needed, dose of > 0.2 mg/kg/day and ≤ 0.2 mg/kg/day respectively. Secondary endpoints were clinical and metabolic syndrome parameters improvement. Body mass index, blood pressure, cholesterol, lipid and glucose levels, were measured before and 12 months after the procedure. Medications to control the comorbidities were also assessed and compared previously and after surgery. Results: There were no intra-operative complications and average operation time was 189 ± 34 minutes. Median hospitalization period was 7.5 days and during post-operative recovery one patient needed surgical hematoma drainage. With a median follow-up of 34 months (range 13-73 months), 100% of the cohort had complete hypercortisolism remission, 20% persisted with latent adrenal insufficiency. Hypercortisolism recurrence was observed in one patient after one yr de follow-up and needed a new PA. Median systolic/diastolic blood pressures were 155/95 before and 123/80 after the procedure (p < 0.001). Median number of medications to control blood hypertension diminished from 3 to 1 (p < 0.001). There was no significant change in cholesterol, lipid and glucose blood levels as well as the number of diabetes and lipid lowering medications. Median BMI decreased from 31.7 ± 7.8 to 28.4 ± 4.7 after the procedure (p = 0.05). Conclusion: Adrenal sparing surgery is a feasible procedure and may provide hypercortisolism remission for patients affected by PMAH, avoiding the drawbacks of lifetime corticosteroids replacement. Furthermore, patients submitted to this surgical treatment exhibited improvement of clinical parameters. Nevertheless, further studies with higher level of evidence and comprising bigger cohorts are necessary to properly analyze the role of this therapeutic modality.

 

Nothing to Disclose: VBB, FYT, VS, MQA, CB, MS, MCNZ, BBM, JLC, MCBVF