CLINICAL MANAGEMENT OF ENDOCRINE DISEASES
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The impact of adrenal tumor multidisciplinary team meetings on clinical outcomes
Hidenori Fukuoka1 . Katsumi Shigemura 2,3 . Maki Kanzawa4 . Tomonori Kanda5 . Masaaki Yamamoto1 .
Koichi Kitagawa3,6 · Mariko Sakamoto2 . Genzo Iguchi7,8 . Wataru Ogawa9 . Masato Fujisawa2 . Yutaka Takahashi9
Received: 22 February 2020 / Accepted: 19 May 2020 @ Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract
Purpose Multidisciplinary team meetings (MDMs) to address various clinical problems have become common, especially for cancer care. However, the impact of MDMs on adrenal tumor care has rarely been reported. We organized an endocrine tumor MDM including adrenal tumors in August 2014. The objective of this study was to assess the impact of our adrenal tumor MDMs on patient clinical outcomes. We compared several parameters measuring clinical outcomes before and after MDMs were instituted.
Methods The adrenal tumor MDMs included an endocrinologists, urologists, radiologists, pathologists, and residents. We analyzed 128 consecutive cases of functioning adrenal tumors (primary aldosteronism (PA), n =53; Cushing’s syndrome (CS), n = 24; pheochromocytoma (PCC), n = 51) who underwent surgery in Kobe University Hospital from 2008 to 2019, and compared clinical parameters before (n = 68) and after (n = 60) MDMs were instituted.
Results Twenty-one selected cases including PA, CS, PCC, adrenocortical carcinoma, and metastatic adrenal tumor were discussed in the MDM. In the analysis of 128 cases, the difference between pre- and postoperative systolic BP (ABP) in patients with PA after MDMs were instituted was smaller compared with those before (p = 0.02). In CS, preoperative steroid synthesis inhibitors were used more often (33 vs. 100%, p <0.01), postoperative plasma ACTH levels were higher (29.1 vs. 84.5 pg/mL, p <0.01), and postoperative decrease in systolic BP was milder (p<0.01) after MDMs were instituted. In PCC, doses of preoperative doxazosin were higher (p<0.01) after MDMs institution. Operating time, bleeding volume, and cure rate did not differ between each tumor type.
Conclusions These data suggest that instituting MDMs improved the perioperative management of functioning adrenal tumors.
Keywords Multidisciplinary meeting . Primary aldosteronism . Cushing’s syndrome · Pheochromocytoma . Education . Perioperative management
☒ Katsumi Shigemura katsumi@med.kobe-u.ac.jp
1 Division of Diabetes and Endocrinology, Kobe University Hospital, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan
2 Division of Urology, Department of Organ Therapeutics, Faculty of Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan
3 Department of Public Health, Kobe University Graduate School of Health Science, 7-10-2 Tomogaoka, Suma-ku, Kobe 654-0142, Japan
4 Department of Diagnostic Pathology, Kobe University Hospital, 7-5-2 Kusunoki-cho, Chuo-ku, CKobe 650-0017, Japan
5 Department of Radiology, Kobe University School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan
6 Division of Advanced Medical Science, Kobe University Graduate School of Science, Technology and Innovation, 7-5-1 Kusunoki- cho, Chuo-ku, Kobe 650-0017, Japan
7 Medical Center for Student Health, Kobe University, Kobe, Hyogo, Japan
8 Department of Biosignal Pathophysiology, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo 650-0017, Japan
9 Division of Diabetes and Endocrinology, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan
Introduction
Multidisciplinary meetings (MDMs) are carried out widely, especially in the cancer field, mainly for making treatment decisions. However, the effectiveness of MDMs for cancer outcomes is variable [1-6]. In functioning adrenal tumors, including primary aldosteronism (PA), Cushing’s syndrome (CS), and pheochromocytoma (PCC), special perioperative management is required mainly due to the tumor’s auton- omous hormone secretion and associated complications. For example, preoperative medical therapy is important for surgical safety in many cases. In PA, preoperative control of blood pressure (BP) and correction of hypokalemia is required [7]. In CS, correction of hypercortisolemia, con- trolling plasma glucose levels and BP, and prophylaxis for venous thromboembolism (VTE) is important [8, 9]. Peri- operative steroid replacement is also essential. In all patients with PCC, presurgical control of HT and intravascular volume correction using alpha-adrenergic blockade and other treatments is needed [10].
In addition, surgical outcome is assessed not only by the success of tumor resection but also by improvement in bio- chemical abnormalities and complications including HT, glucose intolerance, and abnormal lipid profiles. Therefore, multidisciplinary cooperation is necessary for a deeper understanding of adrenal tumor pathophysiology and coop- erative perioperative management. In routine clinical proce- dure, endocrinologists take part in the diagnosis, preoperative management and postoperative follow-up. Surgical and peri- operative management are performed by the urology and anesthesiology department. To build better communication opportunities across these departments, we launched a coop- erative adrenal tumor MDMs composed of endocrinologists, radiologists, pathologists, urologists, and residents in 2014. The purpose of this MDM was to review patient diagnosis and management and update participants on clinical topics. Cases presented to the MDMs are assessed from different points of view and discussed for appropriate diagnosis after reviewing laboratory, imaging, and pathological findings.
To evaluate the efficacy of our adrenal tumor MDMs quantitatively, we compared the clinical parameters before the organization of MDMs (from 2008 to August 2014) and after initiation (September 2014 to 2019). These parameters included pre- and postoperative blood pressure, HbA1c and surgery-related factors including operating time and blood loss.
Materials and methods
This single center retrospective cross-sectional study was approved by the Research Ethics Committee of Kobe Uni- versity Hospital (IRB# 1351). Surgery for all patients was
Table 1 Adrenal tumor MDM agenda
(1) Case presentation by endocrinologists.
(2) Imaging findings review by radiologists.
(3) Operative findings and perioperative procedure and management by urologists and/or anesthesiologists.
(4) Pathological findings review by pathologists.
(5) Postoperative follow-up by endocrinologists.
(6) Short lecture with recent paper review or topics.
(7) Discussion.
performed in the Department of Urology, Kobe University Hospital.
Adrenal tumor MDMs
We organized our cooperative MDMs in August 2014 to include endocrinologists, pathologists, radiologists, urolo- gists, and residents. When necessary, we extended partici- pation to other physicians such as anesthesiologists and oncologists. MDM meetings include summary and feedback a couple of months after surgery. The general agenda for MDMs is shown in Table 1.
The participants for each presented case are multi- disciplinary expert physicians, young physicians, and resi- dents. Information related to the disease and its management, including the perioperative period, is updated in meetings. The standard criteria for case selection include unique clinical points which could be candidates for case reports and clinical difficulties that need to be discussed. To be raised, all cases should be instrumental for all partici- pants. Target cases are all adrenal tumors, including PA, CS, PCC, nonfunctioning adenoma (NFA), subclinical CS (SCS), myelolipoma, adrenocortical carcinoma (ACC), malignant PCC, metastatic tumors, and atypical tumors. The purposes of the conference include (1) networking, (2) updating information related to the disease, (3) education for young physicians and residents, (4) further improvement of clinical management by the team, and (5) connecting the clinical questions to translational research. A flowchart of cooperative diagnosis, presurgical management, surgical findings, and postsurgical follow-up is shown in Table 2. For each MDMs, we prepare presentation slides of the patient, including brief medical history, clinical course, imaging summary, surgical finding, pathological slides, disease topics, and a summary of the discussion points related to the patient, which are shared with all participants.
Comparison study of outcomes before and after instituting MDMs
To investigate the effect of adrenal tumor MDMs on clinical outcomes, we analyzed the clinical parameters of patients
Table 2 Flowchart of cooperative diagnosis, preoperative management, surgical findings, and postoperative follow-up
(1) Consultant of adrenal tumor patients (symptomatic and asymptomatic) to urology or endocrinology.
(2) Evaluate the imaging findings by radiologists.
(3) Evaluate the hormonal function findings by endocrinologists and make a diagnosis.
(4) Presurgical drug treatment (if needed) by endocrinologists.
(5) Consultation to Urology to perform surgery.
(6) Perioperative management by endocrinologists and anesthesiologists, including steroid cover, alpha-adrenergic blockade, and control of mineral or glucose abnormality.
(7) Postsurgical histological evaluation including immunostaining by a pathologists.
(8) Postsurgical hormonal evaluation by an endocrinologist.
(9) Perform endocrine MDM with anesthesiologists, endocrinologists, pathologists, radiologists, and urologists, and re-evaluate the case.
with PA (n=53), CS (n=24), and PCC (n=51) who underwent surgery in Kobe University Hospital from 2008 to 2019. We divided patients into two groups, before the organization of MDMs and after MDMs institution (before/ after; PA (n = 27/26), CS (n = 16/8), and PCC (n = 25/26)). Diagnosis of these diseases was based on clinical features and hormonal evaluation according to individual guidelines [7-9]. Hormone levels under the limits of assay detection were converted as 0. In PA, antihypertensive drugs were changed from mineral corticoid receptor antagonists (MRA), beta blockers (BB), aldosterone receptor blockers (ARB), angiotensin-converting enzymes or antidiuretics into calcium channel blockers (CCB) and/or alpha blockers (AB) at least 6 weeks before the biochemical assessment. After the biochemical diagnosis of PA, drugs were modified to target normal BP in preparation for the surgery. These include MRA, BB, and ARB. Drug resistance was defined as poor control of BP despite the use of three or more drugs. Although NFA, SCS, myelolipoma, ACC, malignant PCC, metastatic tumors, and atypical tumors are important topics in the MDMs, only PA, CS, and PCC were included in this comparison study, since more dynamic changes were expected in these categories and the number of patients was relatively high. The study of VTE included only those patients who were evaluated by lower extremity ultrasound or who had pulmonary embolism.
Statistics
The results were expressed as median and range. The Mann-Whitney U test was used to compare the continuous variables, and a x test was performed to analyze the difference in categorical variables between two groups. p values of less than 0.05 were considered as statistically
significant. All the statistical analyses were conducted using JMP Statistical Database Software version 12 (SAS Insti- tute, Inc. Cary, NC, USA).
Results
Adrenal tumor MDMs
Twenty-one selected patients were discussed in MDMs, including PCC (n=6), malignant PCC (n=1), PA (n=1), CS (n=1), bilateral macronodular adrenal hyperplasia (n=2), PA+SCS (n=1), PCC+CS (n=1), PCC+PA (n=2), NFA (n=2), adrenal ganglioneuroma (n=1), ACC (n= 1), and metastatic adrenal tumor (n =2). Patients were 67% female (n= 14), and the average age was 64 years [range: 32-83]. In the MDMs, pathophysiology, sur- gical outcomes such as HT, postoperative adrenal insuffi- ciency, and need for additional treatment were discussed. Clinical outcomes of these patients were as follows: 13 patients cured, 3 partially improved, 2 unchanged, and 3 required further chemotherapy (a malignant PCC case, an adrenal angiosarcoma case, and an ACC case).
Comparison study of outcomes before and after instituting MDMs
Primary aldosteronism
In patient characteristics, preoperative plasma renin activity (PRA) was higher after the organization of MDMs than before (0.2 [0.1-0.7] vs. 0.4 [0.1-5.5], p = 0.04), suggest- ing an increase in patients with milder forms of PA. After biochemical assessment, drugs were modified to target normal BP in preparation for surgery. The frequency of patients treated with MRA was significantly increased after MDM institution (p<0.01). The difference between pre- and postoperative systolic BP (ASBP) was lower after the organization of MDMs (10 [-12 to 49] vs. 3 [-25 to 33], p=0.02), with slightly higher postsurgical diastolic BP (DBP) (76 [60-92] vs. 81 [58-123] mmHg, p=0.03). Operating time and blood loss volume showed no difference before and after MDMs were instituted (174 [108-249] vs. 196 [121-333] min; p = 0.28, and 0 [0-100] vs. 0 [0-200] mL; p= 0.07), respectively (Table 3).
CS patient characteristics, including gender, BP, anti-HT drugs, and antidiabetes mellitus (DM) drugs showed no significant differences before and after the organization of MDMs except that the ratio of elderly patients was higher (43 [17-69] vs. 49 [42-73] years, p=0.04). Regarding hormonal levels, preoperative serum cortisol (F) levels were lower (21.4 [9.0-44.5] vs. 18.0 [14.1-21.4] ug/dL; p< 0.01), and postoperative plasma ACTH levels were higher
Table 3 Clinical parameters in patients with PA before and after the organization of MDMs
(a)
| n | Before MDM 27 | After MDM 26 | p value |
|---|---|---|---|
| Age (year) | 58 [33-69] | 50 [35-70] | 0.52 |
| Sex (F/M) | 16/11 | 10/16 | 0.17 |
| BMI (kg/m2) | 22.9 [15.6-29.6] | 25.6 [17.1-38.8] | 0.04 |
| Drug resistance (Y/N) | 6/21 | 4/22 | 0.52 |
| Operating time (min) | 174 [108-249] | 196 [121-333] | 0.28 |
| Bleeding volume (mL) | 0 [0-100] | 0 [0-200] | 0.07 |
(b)
| Preoperative | Postoperative | |||||
|---|---|---|---|---|---|---|
| Before MDM | After MDM | p value | Before MDM | After MDM | p value | |
| PRA (ng/mL/h) | 0.2 [0.1-0.7] | 0.4 [0.1-5.5] | 0.04 | 1.2 [0.2-4.7] | 1 [0.2-4.1] | 0.97 |
| PAC (pg/mL) | 362 [50-1782] | 385 [98-1830] | 0.67 | 75 [14-423] | 117.5 [62-190] | 0.06 |
| APRA | -1.2 [-4.5 to 0.2] | -0.7 [-3.7 to 0.2] | 0.66 | |||
| APAC | 258 [-7.6 to 1727] | 356 [-61 to 1144] | 0.86 | |||
| SBP (mmHg) | 134 [108-164] | 132 [108-172] | 0.41 | 124 [100-148] | 130 [100-178] | 0.05 |
| DBP (mmHg) | 78 [56-99] | 78 [57-112] | 0.55 | 76 [60-92] | 81 [58-123] | 0.03 |
| ASBP | 10 [-12 to 49] | 3 [-25 to 33] | 0.02 | |||
| ADBP | 4 [-18 to 24] | -1.5 [-33 to 28] | 0.30 | |||
| Anti-HT drugs (Y/N) | 27/0 | 25/1 | 0.49 | 14/13 | 11/13 | 0.78 |
| CCB (%) | 26 (96) | 20 (77) | 0.07 | 16 (94) | 11 (46) | 0.22 |
| MRA (%) | 6 (22) | 20 (77) | <0.01 | 0 (0) | 0 (0) | |
| AB (%) | 9 (33) | 8 (31) | 0.92 | 1 (4) | 3 (13) | 0.28 |
| BB (%) | 4 (15) | 1 (4) | 0.19 | 2 (7) | 2 (8) | 0.97 |
| ARB (%) | 7 (26) | 1 (4) | 0.03 | 4 (15) | 0 (0) | 0.04 |
after MDMs were instituted (29.1 [0.6-25.9] vs. 84.5 [41.1-162.9] pg/mL; p<0.01). Preoperative treatment with steroid synthesis inhibitors (SSIs) was performed in 3 of 16 (18.8%) patients before MDMs were instituted, and in 7 of 7 (100%) patients after MDMs (p<0.01). Operating time and postsurgical blood loss volume showed no difference before and after MDMs were instituted (173 [123-485] vs. 203 [127-246] min; p = 0.39, and 0 [0-200] vs. 0 [0-130] mL; p=0.32, respectively). Postsurgical anti-HT drugs were given more often after MDMs were instituted (p = 0.03), which might be related to the relatively elderly patients included in this study. Although the number of patients with presurgical anticoagulants was not different, postoperative D-dimer levels were lower after MDMs instution than before (3.4 [0-7.3] vs. 0 [0-3.0], p = 0.04) (Table 4).
Pheochromocytoma
More patients were treated with anti-HT drugs after the organization of MDMs than before (60 vs. 95%; p<0.01).
There were no differences in systolic and diastolic blood pressure (SBP: 126 [92-177] vs. 130 [90-180] mmHg, p = 0.96; DBP: 68 [48-96] vs. 69 [46-118] mmHg; p = 0.51). The dose of preoperative doxazosin was higher after MDMs than before (4.0 [1.0-16.0] vs. 1.3 [0-8.0] mg/day, p< 0.01). Operating time and blood loss volume showed no differences before and after the organization of MDMs (173 [91-374] vs. 187 [97-414] min, p=0.20; 0 [0-900] vs. 0 [0-300] mL, p =0.24, respectively). The number of inci- dents of perioperative HT did not change (30 vs. 32; p = 1.00) and no vital shocks during anesthesia were recorded. Postoperative use of anti-HT drugs and/or antidiabetic drugs showed no difference (33 vs. 19%, p= 0.33; 8 vs. 14%, p = 0.65) (Table 5).
Discussion
In this study we investigated the impact of adrenal tumor MDMs on clinical outcomes. Our MDMs meetings were launched as clinicopathologic conferences (CPCs) and
Table 4 Clinical parameters of patients with CS before and after MDMs were instituted
(a)
| n | Before MDM 16 | After MDM 8 | p value |
|---|---|---|---|
| Age (year) | 43 [17-69] | 49 [42-73] | 0.04 |
| Sex (F/M) | 14/2 | 6/2 | 0.58 |
| Operating time (min) | 173 [123-485] | 203 [127-246] | 0.39 |
| Bleeding volume (mL) | 0 [0-200] | 0 [0-130] | 0.32 |
(b)
| Preoperative | Postoperative | |||||
|---|---|---|---|---|---|---|
| Before MDM | After MDM | p value | Before MDM | After MDM | p value | |
| ACTH (pg/mL) | 0.0 [0.0-0.0] | 2.2 [0.0-3.4] | 0.23 | 29.1 [0.6-114.8] | 84.5 [41.1-162.9] | <0.01 |
| F (µg/dL) | 21.4 [9.0-44.5] | 18.0 [14.1-21.4] | <0.01 | 9.3 [1.1-25.9] | 7.9 [3.2-13.2] | 0.46 |
| ACTH | -29.7 [-114.8 to 0.6] | -81.0 [-162.9 to 37.7] | 0.02 | |||
| ΔΕ | 13.2 [1.6-37.1] | 9.4 [5.0-17.0] | 0.50 | |||
| UFC (ug/day) | 344.5 [33.8-771.0] | 189.5 [96.8-244.0] | 0.09 | 0.0 [0.0-28.0] | 5.6 [0.0-19.5] | 0.22 |
| Anti-HT drugs (Y/N) | 3/13 | 5/2 | 0.62 | 3/13 | 5/2 | 0.03 |
| Anti-DM drugs (Y/N) | 6/9 | 1/6 | 0.35 | 4/12 | 0/7 | 0.27 |
| ASBP (mmHg) | 132 [100-164] | 136 [118-150] | 0.37 | 106 [86-130] | 121 [120-130] | <0.01 |
| ADBP (mmHg) | 77 [60-98] | 82 [68-107] | 0.44 | 68 [42-90] | 72 [60-80] | 0.17 |
| ASBP | 26 [-9 to 53] | 13 [-2 to 30] | 0.10 | |||
| ADBP | 13 [-22 to 40] | 10 [-9 to 40] | 0.97 | |||
| Presurgical SSI (Y/N) | 4/12 | 7/0 | 0.01 | |||
| Metyrapon | 2 | 7 | <0.01 | |||
| Trilostane | 2 | 0 | 0.28 | |||
| Presurgical anticoagulant (Y/N) | 2 | 2 | 0.48 | |||
| D-dimer | 1.9 [0-5.4] | 0.85 [0-1.5] | 0.21 | 3.4 [0-7.3] | 0 [0-3] | 0.04 |
| VTE (Y/N) | 2/3 | 2/2 | 0.50 | 1/5 | ||
developed into MDMs as described in Table 2. Although clinical conferences can be beneficial for all the participants, it is generally difficult to quantify the educational effect. However, in this study, we showed a significant quantitative impact of our MDMs on clinical parameters. Comparing the before and after periods, overall preoperative drug treatment became more careful and appropriate after MDMs. There was less change between pre- and postoperative BPs in PA and CS, and better restoration of ACTH levels after surgery in CS, which may reflect the effect of changes in pre- operative drug treatment.
Tumor board meetings coordinating a team of specialists for cancer treatment are among the most successful repre- sentative MDMs [3]. Generally, these tumor MDMs target malignant tumors and usually do not include benign neo- plasms such as endocrine tumors. In terms of endocrine tumors, to the best of our knowledge only a few reports of MDMs for thyroid cancers have been reported [11]. It has
generally been considered that the significance of MDMs is not obvious for benign tumors. However, there are many issues that need to be discussed in treating adrenal tumors, especially functional tumors. Furthermore, malignant endocrine tumors, though quite rare, are clinically chal- lenging. Therefore, our established team meeting now function promptly to manage these particular cases. In addition, it is important to share perioperative management information between endocrinologists, urologists and anesthesiologists, and the feedback for the members is important for improving clinical practice and communica- tion generally. Indeed, we demonstrated that organizing MDMs measurably improved perioperative management (Tables 4 and 5).
Preoperative medical management, including anti-HT drugs, and changes in BP between pre- and postoperative status were apparently altered after the organization of MDMs. In patients with PA, MRA was significantly used
Table 5 Clinical parameters of patients with PCC before and after MDMs were instituted
(a)
| n | Before MDM 25 | After MDM 22 | p value |
|---|---|---|---|
| Age (year) | 58 [18-84] | 56 [19-75] | 0.32 |
| Sex (F/M) | 10/15 | 14/8 | 0.15 |
| BMI (kg/m2) | 20.6 [16.4-29.2] | 21.8 [15.1-36.3] | 0.22 |
| Operating time (min) | 173 [91-374] | 187 [97-414] | 0.20 |
| Bleeding volume (mL) | 0 [0-900] | 0 [0-300] | 0.24 |
(b)
| Preoperative | Postoperative | |||||
|---|---|---|---|---|---|---|
| Before MDM | After MDM | p value | Before MDM | After MDM | p value | |
| Anti-DM drugs (Y/N) | 5/20 | 5/17 | 1.00 | 2/23 | 3/19 | 0.65 |
| Anti-HT drugs (Y/N) | 15/10 | 21/1 | <0.01 | 8/16 | 4/17 | 0.33 |
| Dox (mg/day) | 1.25 [0-8] | 4.00 [1-16] | <0.01 | 0 | 0 | |
| Perisurgical HT (Y/N) | 7/16 | 7/15 | 1.00 | |||
| Postsurgical CA treatment (Y/N) | 7/18 | 3/19 | 0.30 | |||
| SBP (mmHg) | 126 [92-177] | 130 [90-180] | 0.96 | 126 [92-177] | 118 [93-160] | 0.72 |
| DBP (mmHg) | 68 [48-96] | 69 [46-118] | 0.51 | 68 [48-96] | 68 [53-96] | 0.81 |
| A (pg/mL) | 0.13 [0.02-310.00] | 0.20 [0.02-63.00] | 0.96 | 0.03 [0.01-0.07] | 0.04 [0.03-0.04] | 0.48 |
| NA (pg/mL) | 0.93 [0.22-94.00] | 0.82 [0.16-58,232.00] | 0.43 | 0.44 [0.09-0.82] | 0.31 [0.12-0.77] | 0.31 |
| DOPA (pg/mL) | 0.07 [0.04-2.30] | 0.04 [0.02-566.00] | 0.22 | 0.03 [0.01-0.03] | 0.05 [0.05-0.05] | 0.07 |
| u-A (ug/day) | 67.4 [4.3-1880] | 54.8 [6.1-1020.0] | 0.66 | 5.5 [1.7-10.1] | 6.3 [2.7-19.7] | 0.42 |
| u-NA (ug/day) | 300 [104-7570] | 268 [57-8080] | 0.43 | 106 [33.6-203] | 95 [59-225] | 0.82 |
| u-DOPA (mg/day) | 690 [370-4700] | 690 [310-2603] | 0.80 | 585 [180-870] | 635 [430-880] | 0.52 |
| u-MN (mg/day) | 0.95 [0.08-72.00] | 1.05 [0.05-7.80] | 0.92 | 0.06 [0.02-0.09] | 0.08 [0.05-1.00] | 0.08 |
| u-NMN (mg/day) | 1.20 [0.25-20.00] | 0.94 [0.10-14.00] | 0.33 | 0.20 [0.06-0.44] | 0.17 [0.01-0.72] | 0.71 |
as a preoperative treatment after MDMs and may have suppressed postoperative BP decline. However, the fact that the BMI of patients after MDMs institution was higher than before could also have affected the persistent relatively high BP. In patients with CS, correction of hypercortisolemia by using SSIs was mainly performed for preoperative management rather than HT. The dose of SSIs was significantly increased after MDMs were insti- tuted, with the expectation of reducing perioperative complications and faster recovery of suppressed adrenal function. After MDM, postoperative D-dimer levels were significantly reduced in spite of unaltered anticoagulant pretreatment. There could be several reasons contributing to this change, including stricter preoperative SSI treat- ment or better perisurgical management to prevent VTE. Likewise, in patients with PCC, the doses of preoperative doxazosin and anti-HT drugs were higher after the orga- nization of MDMs. The reason for the relatively lower
doses of doxazosin before MDM remains obscure. Since the catecholamine levels were not different between study periods, at least this MDM may have helped create an environment where it is easier to increase the adjunct dose of doxazosin.
Perioperative management data, such as preoperative medical treatment, obviously showed the effect of MDMs; however, the changes in clinical characteristics may partly stem from other reasons. For example, preoperative PRA was higher in patients with PA, and the prevalence of drug- resistant HT tended to decrease after the organization of MDMs, indicating that relatively mild forms of PA increased. In Japan, the clinical guidelines for PA were published in 2009 and thereafter more appropriate diagnosis and management spread rapidly [12].
In our experience, including a pathologists in meeting feedback was extremely relevant in CPC. The most important point was the way lessons from the discussion were
immediately useful for improving patient follow-up. Face-to- face discussions between endocrinologists, urologists, radi- ologists, and pathologists also made it easy to raise essential clinical questions and clarify points. In particular, these cross- sectional discussions between different field specialists helped everyone understand the different aspects of patient care and they were obviously educational for young resi- dents. As a result, the members of the team were more motivated and their skills became more standardized.
There are limitations in this study. First, it is difficult to differentiate the effect of MDMs from the effects of medical progress, such as guidelines, and from personal improve- ment in medical skills. It is also difficult to set up an appropriate control group. Secondly, this is a retrospective observational study with a relatively small number of patients. Lastly, some of the educational and motivational effects of MDMs are difficult to quantify.
In summary, instituting adrenal tumor MDMs had a measurable impact on clinical parameters such as changes in BP, preoperative medical treatment, and better commu- nication between the members of the patient care team. Our data suggest that the organization of an MDM system improved the perioperative management of functional adrenal tumors.
Acknowledgements We are grateful to Ms. Y. Souki, Ms. M. Sakoda, and Dr. M. Kimura-Koyanagi for providing excellent assistance.
Funding Grant-in-Aid for Scientific Research from the Japanese Ministry of Education, Culture, Sports, Science and Technology 15K09432 (K.S.), 19K09003 (H.F.).
Author contributions H.F., K.S., Y.T. conceived the idea and design for this study. H.F. prepared the draft of the paper with assistance from K.S., W.O., M.F., and Y.T. M.K., T.K., M.Y., K.K., M.S., and G.I. contributed to the study design and provided clinical expertise throughout the project.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of interest.
Ethical approval This study was approved by the Research Ethics Committee of Kobe University Hospital (IRB# 1351).
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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