These studies should be followed by surgical excision for symptomatic lesions or those that are greater than 6 cm in size.21 These larger pseudocysts have been associated with adrenal neoplasms, including adrenal carcinoma, adrenal adenomas, and pheochromocytomas.1 Cysts may be removed via an open or laparoscopic approach.3
Once an adrenal mass is identified, gadolinium-enhanced MRI of the abdomen and pelvis followed by metaiodobenzylguanidine (MIBG) scintigraphy should be considered. MIBG concentrates in the adrenergic vesicles with 80% to 90% sensitivity; 123I MIBG has higher sensitivity and specificity than 131I MIBG and allows for the use of single photonemission CT. Nonlocalized findings should be followed up with chest MRI, positron emission tomography, and/ or OctreoScan imaging to help clarify whether operative, surveillance, or conservative therapy is optimum. FNA of an adrenal cyst could be considered, and suspicious metastatic lesions may be biopsied before any surgical intervention. Once operative plans are made, perioperative alpha-blockade and subsequent beta-blockade is paramount to avoid ontable hemodynamic instability.
When a pancreatic mass is suspected, pancreatic protocol CT should be obtained. Dual-phase cross-sectional imaging of the pancreas and liver in arterial and venous phases is used to detect malignant disease. Thin cuts through the pancreas (2.5 mm reconstructed to 1.25 mm) allow for accurate visualization of small cysts and characterization of both morphology and relationships with major vascular structures. Esophagogastroduodenoscopy and endoscopic ultrasonography with FNA of the cyst should be considered in the face of radiographic ambiguity. Aspirations should be evaluated for amylase, lipase, carcinoembryonic antigen, cancer antigen (CA) 19-9, CA 15-3, and neuroendocrine markers when malignancy is suspected. Every effort should be made to achieve a definitive pathologic diagnosis (serous cystadenocarcinoma, solid pseudopapillary tumor, intraductal papillary mucinous neoplasm, or mucinous cystic neoplasm) to establish surgical risk stratification and staging.22 Endoscopic retrograde cholangiopancreatography or a magnetic resonance cholangiopancreatography may be indicated to delineate the difference between a pancreatic cyst and other pancreatic masses.
MEA CULPA OR INCIDENTAL FINDING?
This discussion underscores many salient features in the investigation of suspected abdominal, pancreatic, and adrenal cystic lesions; the need for collaborative dialogue between surgeons and radiologists is just one of them. The primary team should re-review imaging studies before major surgical exploration. In our patient, the radiographic report suggested no adrenal association. Although the surgical house staff may have reviewed the images, they did not conference with their radiology colleagues to confirm this report. This is a key step that should be completed when developing an operative plan and might have better clarified the anatomic relationships preoperatively (Figure 4). No matter what resources are used to treat a patient, the onus of competence and completeness lies with the surgical team.
Informed consent should be obtained once the technical course, expected risks of the procedure, clinical benefits of the operation, typical expected complications of intervening, and reasonable available alternatives are presented to the patient or the durable health care proxy. Occasionally, the best laid plan becomes complicated by unexpected occurrences, as in this case. Resources are available that outline the expected steps to be followed when such intraoperative findings occur. These texts typically encourage prudence and the use of good surgical judgment. Effective and immediate communication with family members intraoperatively or immediately postoperatively is paramount and may avert future litigation. Sometimes, depending on the type of operation (curative versus palliative) and the type of anomaly traversed, the reasonable course may be to abort the procedure or perform a partial ideal operation and revisit the care plan.
In academic medical centers, patients are evaluated and treated by providers with varying funds of knowledge. At tending surgeons, residents, nonphysician clinicians, and students work together in treating surgical patients. Interdisciplinary and collegial collaboration remains the cornerstone to achieving successful outcomes.
Typically, surgical residents are on rotating monthly schedules and may or may not be familiar with all the nuances of a case or clinical finding. The nonphysician clinician, usually a physician assistant on the surgical team, then becomes the default resource. All members of the team should feel encouraged, supported, and unintimidated when challenging a workup, making suggestions, or raising questions during rounds. Such openness can help uncover occult clinical findings and perhaps prevent a catastrophic and/or sentinel event.
Patient management is usually influenced in myriad ways, including by family members, patients themselves, and by the clinical impressions of nonsurgeons. Operative decision making is constantly challenged and thus should be based on evidenced-based review of the surgical literature. Clinical decisions made outside of such a review may be fraught with avoidable morbidity and even mortality. Patient advocacy and the quest for knowledge should remain the sine qua non of an academic medical center, even if it is impossible to achieve 100% of the time. JAAPA
Castigliano Bhamidipati and Matthew Smeds are in the Department of Surgery, State University of New York Upstate Medical University, Syracuse. The authors have indicated no relationships to disclose relating to the content of this article.
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