Bi-national Review of Phaeochromocytoma Care: Is ICU Admission Always Necessary?

BACKGROUND: Post-operative management after phaeochromocytoma resection includes monitoring of blood pressure and blood sugar, and vigilance for haemorrhage. Guidelines recommend 24 h of continuous blood pressure monitoring, usually necessitating HDU/ICU admission. We hypothesised that most patients undergoing phaeochromocytoma resection do not require post-operative HDU/ICU admission. We aim to describe current Australian and New Zealand perioperative management of phaeochromocytoma and determine whether it is safe to omit HDU/ICU care for most patients. METHODS: We collected retrospective data on patients undergoing excision of phaeochromocytoma in 12 centres around Australia and New Zealand between 2007 and 2019. Data collected included preoperative medical management, anaesthetic management, vasopressor support, HDU/ICU admission and complications. RESULTS: A total of 223 patients were included in the study, 173 (77%) of whom were admitted to HDU/ICU post-operatively. The group of patients treated in ICU was similar to the group of patients treated on the ward in terms of demographic and tumour characteristics, and there were significant differences in the proportion of patients admitted to HDU/ICU between centres. Of patients admitted to ICU, 71 (41%) received vasopressor support. This was weaned within 24 h in 55 (77%) patients. Patients with larger tumours (> 6 cm) and a transfusion requirement are more likely to require prolonged inotropic support. Among patients admitted to the ward, there were no complications that required escalation of care. CONCLUSIONS: Although not widespread practice in Australia and New Zealand, it appears safe for the majority of patients undergoing minimally invasive resection of phaeochromocytoma to be admitted to the ward post-operatively.

Laparoscopic adrenalectomy for a rare 14-cm adrenal schwannoma.

Laparoscopic surgery for adrenal tumors is the gold standard for benign tumors; however, its role for adrenal cancer, metastases, and large suspicious lesions remains controversial. This aspect becomes clinically more important as larger incidentaloma are being detected with increasing frequency. Here, we discuss a rare case of a giant 14-cm adrenal schwannoma, which presented as an incidentaloma and was excised laparoscopically. Epidemiology, histology, and surgical treatment options were reviewed. An abdominal computerized tomography scan of a 30-year-old female weighing 130 kg revealed a large left adrenal mass. Preoperative biochemical and endocrine workup confirmed that it was nonfunctioning. The patient had a laparoscopic adrenalectomy without complication. The nodular tumor measured 145 × 100 × 80 cm in size and weighed 312 g. Histopathology showed myxoid areas and spindle cells arranged in a palisading manner. Mitoses were not observed. Tumor cells were immunohistochemically strongly positive for S-100, but negative for CD117, desmin, and muscle-specific actin. There was no evidence of malignancy. The diagnosis was of a benign schwannoma. Adrenal schwannoma is an extremely rare entity and can grow considerably in size. So far, this is the largest adrenal schwannoma reported in literature. In agreement with a growing number of publications, laparoscopic adrenalectomy can also be used for potentially malignant tumors larger than 10 cm in diameter provided the tumor does not infiltrate into other organs, conversion to open surgery is carefully considered, and resection occurs within the anatomic planes, thus ensuring the intactness of the tumor capsule.

A case of a testosterone-secreting oncocytic adrenocortical carcinoma.

Oncocytic neoplasms are most rarely found in the adrenal gland. They are usually benign and non-functioning. We present a case of a testosterone-secreting oncocytic adrenocortical carcinoma in a 19-year-old female who presented with acne, hirsutism and irregular menses. Clinical investigations revealed an elevated testosterone and DHEA-S and a 4×5 cm left adrenal mass. The tumour was successfully excised. The histology showed the tumour to be comprised of oncocytic cells with granular, eosinophilic cytoplasm, features consistent with an oncocytic carcinoma. This is the first case presented of a testosterone-secreting oncocytic adrenocortical carcinoma.

Thyroid malignancies: a New Zealand South Island thyroid clinic experience 1995-2006.

AIM: To assess the number and histological type of thyroid malignancies occurring in the northern half of New Zealand's South Island (referral population of 553,000). METHODS: Patients with newly diagnosed thyroid malignancies seen at thyroid clinic, Christchurch Hospital between 1995 and 2006 were identified from the thyroid clinic database, and the histological diagnoses and clinical features were reviewed from hospital records. RESULTS: During the 12-year study period, 213 patients with thyroid malignancy were identified. The majority had thyroid cancer of follicular cell origin--184 differentiated thyroid cancers (DTC) and 9 anaplastic thyroid cancers. The DTC patients included 130 with papillary thyroid cancers (PTC)--71%; 33 follicular thyroid cancers (FTC)-18%; and 21 Hurthle cell thyroid cancers (HTC)-11%. One of the papillary cancer patients had a mixed papillary-medullary tumour. The 184 DTC patients included five patients with an immediate family member with thyroid cancer--including a mother-son pair with papillary cancer. Tumours of nonfollicular cell origin included 12 medullary thyroid cancers (6% of primary thyroid malignancies), and all were apparently sporadic, 7 primary thyroid lymphomas, and 2 thyroid metastases. The female-male ratio was >/=2 in all patient groups with primary thyroid malignancies. The median age for both PTC and FTC groups was 48 y, with Hurthle cell, anaplastic, and lymphomas occurring in older patients. The 3 paediatric patients (<16 y) all had PTC. CONCLUSIONS: In the 12-year study period the majority (90%) of thyroid malignancies were of follicular cell origin--184 DTC (papillary 130, follicular 33, and Hurthle 21), and 9 anaplastic cancers. Tumours of non-follicular cell origin were uncommon and included medullary cancers, lymphomas, and metastases. Short-term follow up (median 6 y) confirms that anaplastic thyroid cancer is highly malignant, and the only patients with differentiated thyroid cancer with early cancer deaths had presented with advanced disease and were > 55 years at diagnosis.