Objective:To analyze the clinical features of adrenal metastases and summarize the experience of diagnosis and treatment.Methods:The clinicopathological data of 210 patients with adrenal metastases admitted to Peking Union Medical College Hospital from Jan. 1990 to Jun. 2021 were retrospectively analyzed, and the relevant literature was reviewed. The clinical characteristics, primary tumor types, imaging examination methods and diagnosis and treatment methods of adrenal metastases were summarized.Results:Among 210 patients, 153 were males and 57 were females, with an average age of (60±12) years. The average maximum diameter of the tumor was (4.7±2.6) cm, the maximum was 14.5 cm, and the minimum was 0.5 cm. Tumor occurred in 84 cases on the left, 81 cases on the right, and 44 cases bilateral. The primary tumors of 210 patients were 72 cases of lung cancer, 48 cases of renal cancer, 29 cases of hepatobiliary cancer, 18 cases of colorectal cancer, 11 cases of gastric esophageal cancer, 6 cases of pancreatic cancer, 5 cases of breast cancer, 3 cases of melanoma, and 18 cases of other tumors. 108 patients had no obvious clinical symptoms of discomfort, only found in the review of primary tumor or routine physical examination. 102 were primary disease-related symptoms, and 210 patients had no abnormal endocrine signs such as moon face and buffalo back. The median time from diagnosis of primary tumor to adrenal metastasis was 3 months. 95 cases were diagnosed with primary tumor at the same time. The longest time was 228 months. Of the 210 patients, 203 underwent CT, 99 PET-CT, 74 B-ultrasound and 25 MRI. A total of 122 patients were clinically diagnosed as adrenal metastasis by history and imaging examination. One patient was treated with adrenal photon knife, one patient was treated with adrenal artery embolization chemotherapy, and 21 patients were treated with adrenal radiotherapy or CT-guided adrenal radiofrequency ablation. A total of 88 patients were diagnosed as adrenal metastasis by histopathology. Among them, 12 patients were diagnosed by adrenal puncture under CT guidance, 74 patients were diagnosed by adrenal surgery, and 2 patients were further treated with metastatic tumor resection after adrenal metastasis was diagnosed by puncture. Finally, all patients were diagnosed as adrenal metastasis of malignant tumor by pathology, and they continued to be treated with primary tumor.Conclusions:Lung cancer is the most common type of primary adrenal metastases in our hospital. Most of the elderly men have no obvious endocrine-related symptoms and signs. CT is an effective means of examination, supplemented by B ultrasound or MRI diagnostic accuracy will be further improved, but the diagnosis still depends on histopathological examination. For patients with isolated adrenal metastasis, surgical treatment can significantly improve the prognosis. However, comprehensive treatment should be carried out according to the general situation of patients, the type and biological behavior of primary tumors, and the characteristics of metastatic tumors, so as to achieve the best curative effect.

Interstitial lung disease (ILD) is a heterogeneous disease characterized by diffuse pulmonary parenchyma, alveolar inflammation, and pulmonary fibrosis. At present, there are no ideal tools to diagnose and predict the prognosis of ILD. The application of biological markers can assist in the rapid diagnosis of the disease and guide clinical treatment decisions. Therefore, there is an urgent need for reliable, safety and feasible biomarkers to identify disease progression and treatment of interstitial lung disease, so as to achieve timely, accurate and personalized treatment for patients with interstitial lung disease.

Objective:Investigating the efficacy of unilateral adrenalectomy in treatment for primary pigmented nodular adrenocortical disease (PPNAD).Methods:Clinical data of 26 patients with PPNAD treated in our hospital from January 2013 to June 2023 was retrospectively analyzed.There were 11 males and 15 females, with an average age of (19.4±4.7) years. 25 cases presented with typical Cushing's syndrome, and 16 cases were diagnosed with Carney's syndrome. PRKAR1A gene mutation detected in 8 out of 10 cases. CT showed multiple small nodules on bilateral adrenal glands in 14 cases, unilateral small nodules or mild thickening with normal contralateral glands in 8 cases, and no obvious abnormalities in 4 cases. All patients showed autonomous oversecretion of cortisol by endocrine laboratory tests, with a median 24 h-UFC of 408.35 (334.28, 800.78) μg/24 h and decreased level of adrenocorticotropic hormone. All 26 patients underwent laparoscopic unilateral adrenalectomy, with left side adrenalectomy in 8 cases and right side adrenalectomy in 18 cases.Results:The average surgical duration was (85.2±28.7) minutes, with intraoperative blood loss <50 ml in all cases. The median time to drainage tube removal post-operation was 3 (2, 3) days. One patient developed a postoperative pulmonary infection, and 3 patients required postoperative hormone replacement therapy. The median follow-up duration was 64 (31.5, 103.8) months, and all patients showed alleviation of Cushing syndrome clinical manifestations after operations. 19 patients (73.1%) had their 24 h-UFC levels normalized to a median of 42.0 (22.4, 58.3) μg/24 h within 8.5 (5, 46) days post-surgery. 7 patients (26.9%) did not achieve normal 24 h-UFC levels, yet experienced an average reduction of (73.2±10.4)%. 13 patients (50.0%) did not experience recurrence, with a median follow-up of 51 (7, 89.5) months, including two cases without recurrence at 10 years post-surgery. 13 patients showed recurrent increase in postoperative cortisol levels, with a median of 225.6 (188.9, 397.2) μg/24 h. The median time to increased 24 h-UFC post-surgery was 27 (13.5, 50.5) months, with the longest duration reaching 104 months. Among these, 9 cases exhibited clinical signs and symptoms of recurrence, while 4 cases did not. Of the 13 patients with recurrence, 9 underwent contralateral adrenalectomy or subtotal resection, while 4 were observed with follow-up.Conclusions:Unilateral adrenalectomy could be a surgical treatment option for PPNAD. Despite the recurrence in some patients postoperatively, unilateral adrenalectomy could effectively and rapidly reduce cortisol levels in PPNAD patients and alleviate the clinical manifestations of Cushing syndrome.

Objective:To explore the value of nuclear proliferation index (MIB-1) in the diagnosis and prognosis of adrenal cortical carcinoma (ACC).Methods:A retrospective analysis was conducted on the clinical data of ACC patients and patients with benign adrenal lesions admitted to Beijing Union Medical College Hospital from June 2018 to August 2022. There were 59 cases in the ACC group, 25 males and 34 females, with a male to female ratio of 1∶1.4. Age (46.1 ± 2.1) years old, including 4 cases under 20 years old, 7 cases between 21-30 years old, 11 cases between 31-40 years old, 14 cases between 41-50 years old, 13 cases between 51-60 years old, 8 cases between 61-70 years old, and 2 cases over 70 years old. Body mass index (24.3 ± 2.4) kg/m 2. Systolic blood pressure (149.3 ± 5.2) mmHg (1 mmHg=0.133 kPa) and diastolic blood pressure (93.4±1.7) mmHg. There were 51 cases of typical Cushing's syndrome, 52 cases of hypertension, 44 cases of elevated blood sugar, 16 cases of hypokalemia, and 16 cases of menstrual abnormalities and acne caused by androgen secretion. Laboratory examination: Blood glucose (7.2 ± 0.3) mmol/L, glycated hemoglobin (8.6 ± 1.4)%, total cholesterol (5.7 ± 0.3) mmol/L, and triglycerides (2.0 ± 0.3) mmol/L. 24-hour urine free cortisol (234.4 ± 39.0)μg/24 h, with 46 cases showing an increase, and at 8am, corticotropin releasing hormone (9.5 ± 4.1) pg/ml, with 48 cases showing a decrease. Blood free cortisol (401.2 ± 17.1)μg/dl, with 42 cases of rhythm disappearance. 17 cases showed elevated aldosterone levels. Dehydroepiandrosterone sulfate (713 ± 159)μg/dl, of which 16 cases increased. Neuroenolase (21.2 ± 5.3) ng/ml, of which 27 cases were elevated. Insulin like growth factor-1 was (272.0 ± 42.1) ng/ml, with 26 cases showing an increase. 46 routine high-dose and low-dose dexamethasone inhibition tests were not suppressed. 39 cases of tumors were functional. 59 cases underwent preoperative abdominal and pelvic contrast-enhanced CT, MRI, and B-ultrasound examination, and 21 cases underwent PET/CT examination. The tumors were located in 32 cases on the left, 26 cases on the right, and 1 case on both sides. The maximum diameter of the tumor was (9.6 ± 1.7) cm, with 43 cases ≤10 cm and 16 cases >10 cm. There were 5 cases with lymph node metastasis, 16 cases with distant metastasis, and 11 cases with local invasion. There were 4 cases of tumor ENSAT clinical staging stage Ⅰ(T 1N 0M 0 stage), 27 cases of stage Ⅱ(T 2N 0M 0 stage), 23 cases of stage Ⅲ(T 1-2N 1M 0 stage, T 3N 0M 0 stage), and 5 cases of stage Ⅳ(T 1-4N 0-1M 1 stage, T 3N 1M 0 stage, T 4N 0-1M 0 stage). Six cases were accompanied by tumor thrombi in the central adrenal vein, renal vein, and inferior vena cava. There were 53 cases of benign adrenal tumors, including 26 males and 27 females. Age (44.3±3.2) years old, typical manifestations of Cushing's syndrome in 28 cases, 24-hour urine free cortisol (176.4±41.2) μg/24 h. 27 cases showed disappearance of free cortisol rhythm. Dehydroepiandrosterone sulfate is normal. 23 routine high-dose and low-dose dexamethasone inhibition tests were not inhibited. The maximum diameter of the tumor is (4.2 ± 2.3) cm. T 1N 0M 0 stage patients undergo robotic or laparoscopic radical adrenalectomy, with the resection range including the surrounding lymphoid tissue of the tumor; Patients with stage ≥T 2 underwent open radical adrenalectomy and lymph node dissection. Six cases underwent radical adrenalectomy combined with nephrectomy due to tumor invasion of the kidneys with unclear boundaries. 11 cases of local implant metastasis underwent stereotactic radiotherapy. Nine patients with liver metastasis underwent Interventional Embolization treatment. Three cases with isolated lung metastases underwent surgical resection. Four cases of multiple lung metastases were treated with radiotherapy combined with mitotane. According to the postoperative pathological examination results, record the pathological Weiss score and MIB-1. Analyze the correlation between MIB-1 and clinical pathological indicators and prognosis of patients. Results:There were 59 cases in the ACC group, 35 cases of R0 resection, 19 cases of R1 resection and 5 cases of R2 resection.The postoperative pathological examination showed an average weight of approximately (371±52)g, with 42 cases having a tumor mass ≤ 300 g and 17 cases having a tumor mass>300 g. The positive rate of MIB-1 in the control group was 1% to 5%, while the positive rate of MIB-1 in the ACC group was greater than 5%, the difference between the two groups was statistically significant ( P<0.01). 53 patients diagnosed with capsule invasion, capsule rupture, intravascular tumor thrombus, and MIB-1>10% through postoperative pathological examination were treated with tumor bed radiotherapy and mitotan medication, followed by second-line combination immunotherapy and EDP chemotherapy. The 5-year survival rates of ACC patients with different tumor stages were 65% in stage Ⅰ, 58% in stage Ⅱ, 38% in stage Ⅲ, and less than 5% in stage Ⅳ. The total survival time of the two subgroups with low and high staging was 3.6 years and 1.1 years respectively ( P=0.003), while the disease-free survival time of the two groups was 25 months and 11 months, respectively ( P=0.011). R0 resection has a better prognosis than R1 and R2 resection, and its five-year survival rate is higher ( P=0.03). The 5-year survival rates of R0, R1, and R2 groups were 61%, 31%, and 17%, respectively( P=0.030).Survival analysis showed that adrenal cortical cancer patients with MIB-1 greater than 10% had a worse prognosis, with 5-year OS of 17% and 32% for both groups, respectively ( P=0.021). The Weiss score of the ACC group was (7±2). There were 21 cases in the Weiss score 3-5 group and 38 cases in the 6-9 group, the 5-year survival rates of the two groups were 62% and 19%, respectively ( P=0.017). Conclusions:MIB-1 can serve as an auxiliary diagnostic and prognostic indicator, and high expression of MIB-1 can contribute to the early diagnosis and determination of treatment strategies for ACC.

Interstitial lung disease (ILD) is a heterogeneous disease characterized by diffuse pulmonary parenchyma, alveolar inflammation, and pulmonary fibrosis. At present, there are no ideal tools to diagnose and predict the prognosis of ILD. The application of biological markers can assist in the rapid diagnosis of the disease and guide clinical treatment decisions. Therefore, there is an urgent need for reliable, safety and feasible biomarkers to identify disease progression and treatment of interstitial lung disease, so as to achieve timely, accurate and personalized treatment for patients with interstitial lung disease.

Objective To analyze the clinical characteristics for hypertensive attack during operation and clinical experience of preoperative evaluation and preparation in patients with pheochromocytoma and paraganglioma(PHEO/PGL).Methods A total 219 PHEO/PGL cases from September 2016 to September 2018 were retrospectively reviewed.It included 99 males and 120 females,aged 13 to 76 (average 47) years old.The mean diameter of tumor was 5.3 cm (1.5-18.0 cm).140 cases were unilateral PHEO,6 cases were bilateral PHEO,68 cases were PGL(jugular,mediaphragm,heart,retroperitoneum,pelvic and bladder) and 5 cases were PHEO combined with PGL.Preoperative highest systolic blood pressure (SBP)was 240 mmHg(1 mmHg-0.133 kPa) and highest diastolic blood pressure (DBP) was 160 mmHg.20 cases were occult PHEO without hypertension.217 cases accepted preoperative preparation of alpha-blocker [phenoxy-benzamine,dosage ranging from 5 mg Q12h to 40 mg Q8h,maximum dosage not exceeding 1 mg/(kg· 24 h)].2 cases did not accept preoperative preparation.All cases accepted open or endoscope surgery.The patients were divided into 2 groups depending on the presence or absence of hypertensive attack at the time of surgery.Patient demographic characteristics and preoperative evaluations were assessed for their prognostic relevance with respect to hypertensive attack.Results Histopathological results showed that all cases were PHEO or PGL,while 205 cases were benign,14 cases were malignant.Hypertensive attack were recorded in 112 cases(51％).The diameter of tumors in the hypertensive attack group were larger than that in the non-hypertensive attack group[(6.70 ± 2.95)cm vs.(3.95 ± 1.70) cm,P =0.005].There was no significant difference between the two groups among age [(51.0 ± 10.8) years vs.(38.5 ± 17.6) years,P =0.105],preoperative catecholamine level [norepinephrine (111.20 ± 41.49) μg/24 h vs.(419.15 ± 154.81) μg/24 h,P =0.075],time of use of alpha blockers [(53.0 ± 7.5) d vs.(38.0 ± 6.4) d,P =0.139],daily dosage of alpha blocker [(40.0 ±7.2)mg vs.(27.1 ± 1.8) mg,P =0.111] and blood pressure at diagnosis[(173.75 ± 26.69) mmHg vs.(155.0 ± 20.75) mmHg,P =0.139].Among 219 cases,2 case had emergency hemostasis after operation,1 case had catecholamine cardiomyopathy after operation for occult pheochromocytoma,and no perioperative death occurred.Conclusions Patients with large tumor tend to have hypertensive attack during operation so that should be better prepared.

Objective: To evaluate the prognostic value of the thrombolysis in myocardial infarction (TIMI) and global registry of acute coronary events (GRACE) risk scores for in-hospital mortality in Chinese non-ST-segment elevation myocardial infarction (NSTEMI) patients. Methods: Data of present study derived from the prospective, multi-center registry trial of Chinese AMI (CAMI). Among 31 provinces, municipalities or autonomous districts in China, at least one tertiary and secondary hospital was selected. From January 2013 to September 2014, 5 896 consecutive non-ST-segment elevation myocardial infarction patients who were admitted to 107 hospitals within 7 days of symptom onset were enrolled. For each patient, TIMI and GRACE risk scores were calculated using specific variables collected at admission. Their prognostic value was evaluated by the endpoint of in-hospital mortality. Results: Among 5 896 NSTEMI patients (age was (65.4±12.1) years old), 68.2% (n=4 020) were males. The in-hospital mortality was 6.0% (n=353) and the median length of hospital stay was 10.0 (7.0, 13.0) days. The incidence of pre-hospital cardiac arrest was 3.6% (n=213) among 5 896 NSTEMI patients. Six hundreds and forty five patients (10.9%) received primary percutaneous coronary intervention, and 6 patients underwent emergent coronary artery bypass grafting surgery (0.1%), and the median time of reperfusion was 529.5 (256.0, 1 065.0) minutes. The prescription percentage of statins, β-blocker, angiotensin converting enzyme inhibitors or angiotensin Ⅱ receptor blockers, and aldosterone antagonists were 94.8% (n=5 587), 71.7% (n=4 228), 65.5% (n=3 864) and 26.0% (n=1 533) respectively. The area under the curve of GRACE risk score for in-hospital mortality (0.7930 (95%CI 0.767-0.818)) was better than that of TIMI risk score (0.5588 (95%CI 0.532-0.586), P<0.001). Conclusion GRACE risk score demonstrates better predictive accuracy than TIMI risk score for in-hospital mortality in NSTEMI patients in this patient cohort.

Objective We aimed to investigate the overexpression of succinic dehydrogenase (SDH) B and MIB-1 in patients with pheochromocytoma/paraganglioma(PHEO/PGLs) and its significance for predicting the clinical malignant behavior.Methods From August 2008 to April 2016,the clinical characteristics of 93 patients with PHEO/PGLs were analyzed retrospectively.There were 57 males and 36 females,with an average of 34 years,ranging 8-73 years old.There were 68 cases of adrenal pheochromocytoma and 25 cases of paraganglioma.There were 79 cases with hypertension and 14 cases of adrenal accidental tumors.Sixty-six cases with typical hyper-catecholamine secretion symptoms and 27 cases with non-functional PHEO/PGL.Benign PHEO/PGLs were 77 cases and malignant 16 cases.The tumor was located on the left side in 39 cases,on the right side in 32 cases and multiple lesions in 22 cases.The diameter of the PHEO/PGL tumor was (6.8 ± 2.7) cm.The 24 h urine catecholamine was measured before operation,which showed epinephrine was (42.6 ± 5.1) μg/24 h,norepinephrine was (167.5 ± 13.5) μg/24h and dopamine was (246.4 ± 71.2)μg/24h.Six cases wihtout hereditary diseases of urinary system were selected as normal control group.SDHB,SDHAF2,SDHC,SDHD,VHL and RET gene mutations were detected in all patients.Immunohistochemical panel has been performed to detect the expression of SDHB,MIB-1,EPAS1,VEGF-1 receptor (VEGF-1 R),and chromain A (CgA) in 93 specimens of PHEO/PGL tissue.The positive granular cytoplasm staining ＞ 50％ was strongly positive (+ + +),11％ to 50％ was moderately positive (+ +),1％ to 10％ was weak positive (+) and the negative was compared with the known positive internal reference,that is,there was less than 1％ or no stain completely.Results SDHB,SDHAF2,SDHC,SDHD,VHL and RET gene mutations in 27 cases (29.5％).Nine patients with SDHB gene mutation (9.7％).RET proto-oncogene mutations in 8 cases (8.6％).3 cases had VHL mutation (3.2％).Immunohistochemical staining showed that MIB-1 positive expression was found in 7 of 9 patients with SDHB gene mutation.Six cases in the control group were negative for gene detection and MIB-1,EPAS1,CgA and VEGF-1R immunohistochemical results.EPAS1 showed moderately positive in patients with PHEO/PGL and strong positive in patients with malignant PHEO/PGL.In 9 cases with SDHM mutation,EPAS1 was noticed positive in seven cases,which showed the relationship with CgA,MIB-1 and VEGF-1R.Conclusions The SDHB gene mutation is usually shown as a paraganglioma focus outside the adrenal gland.And 9.8％ of the paragangliomas were associated with a mutation of the SDHB gene with an increase in malignant risk.The SDHB mutation caused over-expression of MIB-1 and the positive expression of EPAS1 and VEGF-1R in PHEO/PGL tissues,which was associated with invasion and metastasis of malignant PHEO/PGL.

Objective To assess the long-term outcome of unilateral adrenaletomy in patients with adrenocorticotropic hormone independent macronodular adrenal hyperplasia (AIMAH).Methods The data from 82 cases of AIMAH were reviewed and summarized including clinical manifestations, endocrinological data, imaging findings and postoperative follow-up.Fouty-nine males and thirty-three females with a mean age of fifty years composed our series.Among the 82 cases, 41 demonstrated Cushing syndrome (CS), 74 presented with hypertension, 38 manifested diabetes mellitus, 35 complicated of osteoporosis and 11 of them with bone fracture, 39 complained of edema.Laboratory tests showed low ACTH plasma levels (＜ 2.2 pmol/L) in 62 of 79 cases.High level of 24-hour urinay free cortisol excretion(＞ 284.2nmol/L) was found in 67 of 79 cases.Elevated serum cortisol with loss of the circadian rhythm was presented in 55 of 60 cases.Failed to suppress cortisol secretion was observed in 61 of 63 conducted with low-dose dexamethasone suppression tests and in 47 of 53 implemented with high-dose dexamethasone suppression tests.Bilateral massively enlarged multinodular adrenal glands were found in all cases with CT or MR imaging.Unilateral adrenalectomy was performed in the larger side of adrenal gland in all 82 cases.All adrenalectomies were carried out including 47 in right sides and 35 in left sides, with 77 by retroperitoneoscopic approach and 5 by open retroperitoneal approach.Results Histopathological examination confirmed nodular hyperplasia of the adrenal cortex for all specimens.After a mean duration of 48.5 months, 80 of 82 patients were available for follow-up.Most clinical symptoms resolved within 6 months after operation.Cushingoid features disappeared in 58.5％ (24/41)of patients who initially presented with typical signs of Cushing Syndrome.Weight loss was seen in 56.3％ (45/80).Improvement of hypertension and diabetes was observed in 63.5％ (47/74) and 76.3％ (29/38) respectively.All the eyelids swelling and edema of the limbs subsided within 3 months.In long-term follow-up (more than 6 months), 82.9％ (63/76) had clinical and biochemical recurrence within a mean time of 14.6 months and 46.0％ (29/63) received contralateral adrenal surgery.Two patients died, one died from heart attack and another one died from pulmonary infection, 2 years and 7 years after unilateral adrenalectomy, respectively.Conclusions Unilateral adrenalectomy just has transient efficiency for AIMAH.Most patients will experience clinical and biochemical recurrence for a long period,and have to receive another operation for the contralateral hyperplastic adrenal gland.

Objective To investigate the efficacy and safety of 3D-laparoscopic surgery in adrenalpheochromocytomas /paragangliomas.Methods From December 2012 to July 2014,23 cases of adrenal pheochromocytomas/paragangliomas were treated by 3D-laparoscopic surgery.Among them,7 cases were male and 16 cases were female,whose mean age are 47 (32-68) years old.Their clinical symptoms including sustained hypertension in 11 cases,intermittent hypertension in 8 cases,sustained hypertension with intermittent progression in 2 cases and asymptom in 2 cases.All tumors were diagnosed by endocrine examination,image test and nuclear medicine.Mean diameter of tumors are 8 cm,ranged from 3-14cm.In order to adjust the blood pressure,patients took α-receptor blocker for 2-4 weeks preoperatively.Under the general anesthesia,19 patients received the 3D-laparoscopic surgery via retroperitoneal approach and 4 cases received the procedure via peritoneal approach.Results All operations were completed successfully.There were no major intraoperative complications.Mean operating time was (78 ± 21) min and mean estimated blood loss was (54.8 ± 36.3) ml.Mean hospital stay after operation was (3.8 ± 1.4) days.The pathological diagnosis included pheochromocytomas in 15 cases and paragangliomas in 8 cases.During the 3 to 18 months following up,no recurrence or metastasis was found in this study.Conclusions 3D-laparoscopic surgery has obvious advantage in spatial location and the sense of depth for adrenal pheochromocytomas /paragangliomas,which shortens the operation time and increase the safety obviously.