adrenocortical carcinoma resection

Whether the lesion is caused by tumor or proliferation, its main manifestations are the systemic changes caused by the excessive production of cortisol-based hormones. If it is a tumor, the course of disease is short and develops rapidly, and the symptoms and signs are typical; if it is caused by bilateral hyperplasia, the course of disease is longer and the development is slow. The clinical features of adrenal hyperplasia caused by pituitary tumors or ectopic ACTH tumors differ from the above two categories in some respects. Since Cushing first reported the disease in 1932, 10 cases were diagnosed in the first 20 years, which is considered rare. However, in fact, this disease is not uncommon. With the improvement of cognition and the perfection and accuracy of the means of diagnosis, the number of cases in China has increased dramatically. According to the etiology analysis, the bilateral hyperplasia was not determined by pituitary-dependent cortisol and the cause was about 65%, adrenal adenoma or cancer accounted for about 20%, and ectopic dermal progesteroma accounted for about 15%. Class 1 requires more adrenal surgery; Class 2 can only perform adrenal surgery; and Class 3 belongs to the scope of surgery for each target organ, such as mediastinum, pelvic organs, secondary to cortical hyperplasia After resection, it will subside on its own, and no need for adrenal surgery. Adrenal cortical cancer is rare. Primary cortical cancer can occur at any age. In children with Cushing syndrome, cancer is a common cause and occurs mostly in girls. The tumor grows fast and the course of disease is short. When the tumor is found in the clinic, the tumor is often larger, and the tumor is often touched in the upper abdomen. A large number of corticosteroids produced by tumors, due to the insufficiency or blockage of C11 or C21 hydroxylase, the various cortisol precursors in the body, cortisol, corticosterone, aldosterone, adrenal androgen, progesterone, etc. There are different proportions of increase, so there can be Cushing syndrome, but also can show adrenal genital abnormalities, such as female masculinity, precocious puberty, male feminization. Electrolyte abnormalities, high blood pressure and other symptoms are also very obvious. However, due to the lack of true cortisol secretion, the typical Cushing syndrome is often not seen in the early stage until the tumor grows to a large extent, metastasis, and even later, it is diagnosed. About 50% die within 2 years, and about 1/4 can get clinical cure for more than 3 years after surgical removal of the tumor. Excision of part of the tumor can relieve symptoms and prolong survival. The endocrine function of residual cancer tissue or metastatic cancer can be controlled by drugs. The commonly used chemical agents are o-, p-dichlorophenyl dichloroethane (Mitotane, o, p'DDD, also known as Mentrol), ammonia ubmet, Also known as amino-induced sleep energy or aminoglutethi-mide (aminoglutethi-mide). O,p'DDD can reduce the endocrine function of cortical cancer by more than 50%. Due to the significant reduction in the amount of synthetic real cortisol, insufficient physiological requirements, the role of ACTH during the pathological feedback mechanism often leads to the proliferation of cortex beyond the cancer. The systemic reaction of the drug, especially the gastrointestinal symptoms, is heavier, forcing the drug to stop midway. The early endocrine effect of drug inhibition is better, the effective inhibition period is 4.8 months, and the effective rate is about 50% (Luton, 1990). There are also reports of cases of complete tumor disappearance. Therefore, cortical cancer is still treated with surgery. Primary, medical treatment can be used as an adjuvant therapy, or for tumors that cannot be surgically removed, and must be used in combination with hydrocortisone. Because the tumor infiltrates quickly, the metastasis is early and it is difficult to eradicate. Treatment of diseases: adrenal tumors, adrenal insufficiency Indication Adrenal cortical cancer resection is applicable to: Surgical treatment is the preferred method for adrenal tumors found to be functional and whether they are benign or malignant. Even if there is invasive and metastatic cancer, the opportunity of surgical resection should not be abandoned. Although it is impossible to completely remove the tumor and remove part of the tumor, it will help to alleviate the symptoms and control the rapid development of the disease and improve the efficacy of the adjuvant. Contraindications 1. Liver and lung have a wide range of metastatic cancer. 2. Local infiltration is extensive, involving large blood vessels, the tumor is huge, and the surrounding tissue is fixed and cannot be removed. 3. Late elderly patients, suffering from important life organ diseases, can not tolerate anesthesia and surgery. Preoperative preparation 1. Preoperative treatment of drugs that block the synthesis of cortisol to relieve symptoms and facilitate surgery. The commonly used effective drugs are: O-, p-dichlorophenyldichloroethane (o, p'DDD): This drug can selectively block the band-like and reticular cell functions, and can reduce the secretion of cortisol by more than 50%. The daily dose is 3 ~ 6g, the maximum dose can be increased to 8 ~ 10g, and the tumor of primary cancer and metastatic cancer can be reduced, and the surgical resection rate is improved. It is also effective in the failure to remove or remove unrecovered residual tumor tissue. The drug should be given slowly or not completely disappeared after the operation, but it does not prevent the recurrence of cancer in the long term. Symptoms of digestive tract reaction are more common and can only be used shortly within 3 days before surgery. Aminoglutethimide: also has the effect of inhibiting the synthesis of corticosteroids. The daily dose is 0.75 to 2 g. Preoperative application can alleviate symptoms and can also be used as a conservative treatment for residual cancer tissue and metastatic cancer. Metopirone (SU4885): It has the function of inhibiting hydrogenase, which affects the synthesis of corticosteroids and reduces the symptoms before surgery. The dose is 250 to 500 mg / 6 h. If the corticosteroid secreted by the cancer is dominated by male and cortisol precursors, and the true cortisol content is insufficient, hydrocortisone may be added in combination with the above-mentioned blocker to reduce the feedback stimulation to the pituitary. , reduce the secretion of ACTH. The dose is 50 mg, 1 to 3 times a day. Hydrocortisone replacement therapy should be routinely used after surgery. According to the completeness of tumor resection, the degree of compensatory atrophy of the contralateral adrenal cortex, the time and dose of postoperative medication were adjusted, and the dose was gradually decreased until it was completely stopped. ACTH treatment is generally not used after surgery, waiting for the cortical function to recover naturally. To reduce the effect on the electrolyte, dexamethasone can be used instead of hydrocortisone. 2. Other preoperative preparations are the same as general adrenal and kidney surgery. Surgical procedure Smaller tumors, optionally with a back or lumbar incision, are removed via the extraperitoneal route. The tumor is large, and it can be invaded by the abdomen in the abdomen. The longitudinal incision from the side of the tumor enters the abdominal cavity, and the peritoneum is extensively cut through the paracolic sulcus. The posterior peritoneal space is completely exposed and the abdominal aorta is exposed. The vena cava facilitates the removal of the para-aortic lymphoid tissue for the purpose of removing the tumor and adrenal gland. If one side of the kidney has been violated and the contralateral kidney is normal, it can be removed together with the affected side of the kidney. For adrenal cortical carcinoma with large tumors and local infiltration, the combined chest and abdomen incision is often used. Excision of giant adrenal cortical carcinoma by extrapleural thoracoabdominal surgery can also be satisfactorily revealed, and the disadvantages of incision of the rib arch are avoided, and the chest cavity is not contaminated. Undoubtedly, the rate of surgical resection is higher than other routes, and the chances of adrenal cancer and infiltrating tissue being removed by the whole block are also more. If the abdominal incision is still not large enough, it can be extended downwards, so it is a recommended surgical path. Here, the left adrenocortical carcinoma resection is performed on this path. 1. Cut the chest wall and the abdominal wall Cut the skin, subcutaneous tissue, latissimus dorsi and part of the posterior inferior serratus in the direction of the incision, and cut the external oblique muscle, the internal oblique muscle and the transverse abdominis muscle forward, and cut the ipsilateral rectus abdominis anterior sheath and Cut the rectus abdominis. 2. Incision of the intercostal muscle Carefully cut the intercostal muscle along the 10th intercostal space, taking care not to cut the pleura underneath, and the diaphragm can be seen below the incision. 3. Cut the diaphragm The lungs are filled with oxygen, the lower edge of the lungs is filled with the chest cavity, the pleural reflexes are bluntly separated by fingers, and the pleura is pushed up. The diaphragm is cut outside the pleura along the upper edge of the 11th rib, and the two margins of the diaphragm are respectively separated. The suture is fixed on the muscles of the lower back and the margins on both sides to protect the push-up pleural reflex, so that the surgical field is isolated from the chest to avoid chest contamination. 4. Reveal the retroperitoneal space The posterior rectus abdominis and the peritoneum were cut inward and inward into the abdominal cavity. Push the peritoneal viscera to the medial side, cut the peritoneum of the paracolic sulcus, and cut the posterior peritoneum and spleen colon ligament on the left side of the descending colon on the left side, and free the spleen and descending colon of the colon to the inside and the lower side, so that the left retroperitoneum The gap is widely revealed. 5. Reveal the adrenal gland The perirenal fascia is dissected and the perirenal fat is separated. The kidney, adrenal gland and its giant tumor are exposed to the field of view. 6. Excision of the adrenal gland and tumor After the tumor is revealed, it is released along its periphery. The blood vessels are ligated, but such large adrenal cortical carcinomas are mostly infiltrated into the kidneys and are not easily separated from the kidneys. In order to completely remove the tumor, if the contralateral kidney is normal, the adrenal gland and its tumors should be removed together with the kidney, perirenal adipose tissue and lymphatic mass. This surgical technique and procedure are basically the same as radical nephrectomy. complication In patients with a long-term illness, if the cancer is completely removed by surgery, it is necessary to prevent the occurrence of adrenal cortical crisis. If there is such a sign, continuous infusion of hydrocortisone vein requires a larger dose (100-200 mg, 2/d). When you are able to take it orally, gradually change to oral corticosteroids and reduce the dose according to the situation.