Principles and Management of Adrenal Cancer

182 Pages·1987·9.414 MB·English

by  N. Javadpour (auth.), Nasser Javadpour MD (eds.)

Nasser Javadpour (Editor)
Principles and
Management of
Adrenal Cancer
With 121 Figures
Springer-Verlag
London Berlin Heidelberg New York
Paris Tokyo
Nasser Javadpour. MD. Professor and Director.
Section of Urologic Oncology. Department of Surgery.
School of Medicine. University of Maryland.
University Hospital. Baltimore. Maryland 21201. USA
ISBN -l3:978-1-4471-3l36-6 e-ISBN-l3:978-1-4471-3134-2
DOl: 10.1007/978-1-4471-3134-2
British Library Cataloguing in Publication Data
Principles and management of adrenal cancer.
1. Adrenal glands-Tumors
I. Javadpour. Nasser
616.99'445 RC280.A3
ISBN -13:978-1-4471-313 6-6
Library of Congress Cataloging-in-Publication Data
Principles and management of adrenal cancer.
Includes bibliographies and index.
1. Adrenal gland----Cancer. I. Javadpour. Nasser. 1937-. [DNLM: 1. Adrenal Gland Neoplasms. WK 780 P957j
RC280.A3P75 1987616.99'44586-31443
ISBN -13:978-1-4471-3136-6
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© Springer-VerIag Berlin Heidelberg 1987
Softcover reprint of the hardcover 1st edition 1987
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2128/3916/543210
Preface
The vast amount of literature and rapid developments in the understanding and man
agement of adrenal diseases have outpaced the ability of physicians to assimilate and utilize
these advances in clinical settings. This book is designed to bring these developments to
those interested in adrenal diseases and to assist clinicians in caring for patients with such
diseases.
The recent advances in the understanding of steroids, catecholamines, and utilization of
computed tomography and magnetic resonance imaging have rendered disease of the
adrenal gland more rewarding in terms of early detection.
Although a number of basic and clinical improvements have been achieved in these
diseases, there are still a number of unresolved problems, including the lack of effective
cytotoxic agents for therapy of various disseminated adrenal malignancies.
The natural history of certain diseases of the adrenal glands and their proximity to the
genitourinary system makes these essential organs very attractive to urologic surgeons.
Furthermore, for a number of diseases such as adrenogenital syndrome, hypertension, and
certain tumors of these glands it is obviously desirable that urologic surgeons are familiar
with diseases of "the adrenal glands."
The first part of this book is an overview of the relevant embryology, anatomy, physiology,
markers, pathology, imaging, and current progress. The second part covers specific diseases
of the adrenal cortex and medulla. We hope that this volume will assist the physician in
the diagnosis and management of patients with adrenal disease.
Baltimore, D.S.A. Nasser ]avadpour
February 1987
Contents
Chapter 1 Overview of Progress, Current Problems, and Perspectives
N. Javadpour. . . . . . . . . . . . . . . 1
Chapter 2 Embryology, Anatomy, Physiology, and Biologic Markers
N. Javadpour. . . . . . .. ..... . 15
Chapter 3 Pathology
E. E. Lack and H. P. W. Kozakewich . . . . . . . . . . . . 19
Chapter 4 Advances in Diagnosis
T.H.Hsu .... 57
Chapter 5 Imaging Techniques
D. R. Bodner, C. L. Schultz. and M. I. Resnick ....... 69
Chapter 6 Adrenal Disorders in Childhood
S. A. Chalew . . . . . . 83
Chapter 7 Primary Aldosteronism
J. H. Mersey . . . . . . . . . . . . . . 95
Chapter 8 Cushing's Syndrome
P. A. Levin. . . . . . . . . . . . . . . . . . 107
Chapter 9 Carcinoma
A. Zabbo. R. A. Straffon, and J. E. Montie . . . . . . . . . . 113
Chapter 10 Pheochromocytoma
B. P. M. Hamilton . 121
Chapter 11 Neuroblastoma
B. L6pez-Ibor and A. D. Schwartz . . . . 141
Chapter 12 Metastatic Disease
J. H. Mersey . . . . . . . . . . . . . . . . . 153
viii Contents
Chapter 13 Surgical Management
N. Javadpour . 165
Subject Index. 175
Contributors
D. R. Bodner. MD
Assistant Professor. Division of Urology. Case Western Reserve University. Cleveland. OH
4416. U.S.A.
S. A. Chalew. MD
Assistant Professor of Pediatrics. Division of Pediatric Endocrinology. Bressler Building. Rm
10-047. University of Maryland School of Medicine. Baltimore. MD 21201. U.S.A.
B. P. M. Hamilton. MD
Chief of Endocrinology and Metabolism. Veterans Administration Medical Center.
Baltimore. MD 21218. U.S.A.
T.H. Hsu. MD
Assistant Professor. Department of Medicine. Johns Hopkins Hospital. 600 North Wolfe
Street. Baltimore. MD 21205. U.S.A.
N. Javadpour. MD
Professor and Director. Section of Urologic Oncology. University of Maryland. University
Hospital. Baltimore. MD 21201. U.S.A.
H. P. W. Kozakewich. MD
Assistant Professor of Pathology. Harvard Medical School. Children's Hospital. Boston. MA
02155. U.S.A.
E. E. Lack. MD
Chief of Surgical Pathology and Post-Mortem Section. National Cancer Institute. National
Institutes Of Health. Bethesda. MD 20205. U.S.A.
P. A. Levin. MD
Assistant Professor of Medicine. Department of Pediatrics. University of Maryland School
of Medicine. Baltimore. MD 21201. U.S.A.
x Contributors
B. L6pez-Ibor. MD
Fulbright Fellow in Hematology and Oncology. University of Maryland School of Medicine.
Baltimore. MD 21201. U.S.A.
J. H. Mersey. MD
Assistant Professor. Division of Endocrinology. University of Maryland School of Medicine.
Baltimore. MD 21201. U.S-A.
J. E. Montie. MD
Professor and Chairman. The Department of Urology. The Cleveland Clinic Foundation.
9500 Euclid Avenue. Cleveland. OH 44106. U.S.A.
M. I. Resnick. MD
Professor and Chairman. Division of Urology. Case Western Reserve University. Cleveland.
OH 44106. U.S.A.
C. L. Schultz. MD
Assistant Professor. Division of Radiology. Case Western Reserve University. Cleveland. OH
4416. U.S.A.
A. D. Schwartz. MD
Chief of Pediatric Hematology /Oncology. University of Maryland School of Medicine.
Baltimore. MD 21201. U.S.A.
Chapter 1
Overview of Progress, Current Problems, and
Future Perspectives
N. Javadpour
Recent advances in imaging and localization of a superior renal vein may occasionally be confused
adrenal tumors have had a remarkable impact on with the adrenal vein. Even when the adrenal vein
their surgical and medical management. Advances is accurately catheterized, the concentration of
have also been made in the basic understanding aldosterone will depend on whether the sample is
of pituitary and adrenal function, and meaningful obtained proximal or distal to the entrance of the
progress has been made in localization of tumors inferior phrenic vein (Fig. 1.1).
including venous sampling [8], computed tom
ography [9], magnetic resonance imaging, and
brush biopsies of the intracaval tumor thrombi. A
number of problems remain, the most immediate
being a need for effective chemotherapeutic regi
mens in the management of local recurrences and
disseminated adrenal tumors. In this chapter, I will
review briefly the recent advances in the diagnosis
and therapy of adrenal diseases with emphasis on
surgical problems.
Adrenal Vein Sampling
The most definitive method of localizing adrenal
aldosterone-producing adenomas has been selective
adrenal vein catheterization with sampling of aldo
sterone concentrations [9]. Adrenal vein sampling
is, in most cases, a safe and effective method of
localiZing an aldosterone-producing tumor. The
technical adequacy of catheter placement in the
adrenal vein, particularly on the right, is a critical Fig. 1.1. Catheterization of the left renal vein with injection of
factor in the accuracy of this test. On the left side, contrast material.
2 Overview of Progress. Current Problems. and Future Perspectives
Fig. 1.3. Catheterization of the left adrenal vein with sampling
Fig. 1.2. A small aldosteronoma of the right adrenal gland with and injection of the vein. Note a large hypervascular aldo
a moderately hypervascular adenoma. steronoma of the right adrenal gland.
On the right side, the main problem is differ
entiation of the adrenal vein from the hepatic veins.
Small hepatic veins may enter the inferior vena
cava at the same level as the adrenal vein. Occasion
ally, the right adrenal vein drains into a hepatic or
inferior phrenic vein (Figs. 1.2-1.4).
The use of the ratio of aldosterone to cortisol
concentration in the adrenal vein to that in the
inferior vena cava has been helpful in lateralizing
adrenal adenoma [18]. By determining the level of
cortisol in venous samples, a measure of the dilution
of the adrenal efflux may also be gained. The aldo
sterone-cortisol ratio then reflects the aldosterone
secretion corrected for the degree of selectivity of
catheterization. Adrenal cortisol secretion is also
unaffected by the aldosterone levels and provides a
measure of the degree of accuracy of the adrenal
vein sample. Thus, the ratio of aldosterone to cor
tisol affords a measure of the hypersecretion of aldo
sterone independent of the purity of the sample.
Tumor localization is also an integral part of
the surgical management of pheochromocytoma.
Although the diagnosis may be suspected from the Fig. 1.4. A hypervascular tumor of the left adrenal gland.