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Adrenal Mass Nov 2020.pptxnsdmbns,mfnbsf

adrenal

Health & Medicine◦
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Dr. Samuel L. 1 ADRENAL MASS Presenter: Dr. Samuel L. (GSRIII) Moderator: Dr. Endale A. Consultant General & Endocrine Surgeon
08/17/2025 Dr. Samuel L. 2 OUTLINE OF PRESENTATION  Brief embryology, anatomy & physiology  Hyperaldosteronism  Cushing syndrome  Pheochromocytoma  Adrenocortical cancer  Incidentaloma  Miscellaneous adrenal masses  Techniques of adrenalectomy
08/17/2025 Dr. Samuel L. 3 OBJECTIVES After the end of this session, we will be able to know  the differential diagnoses of adrenal masses  different diagnostic & management algorithms to each disease entity  techniques of adrenalectomy
08/17/2025 Dr. Samuel L. 4 EMBRYOLOGY  The cortex originates around the 5th week of gestation from mesodermal tissue near the gonads  The cortex differentiates further into a thin, definitive cortex and a thicker, inner fetal cortex  Zona reticularis is formed after birth at around 3 years of age  Medulla is ectodermal in origin and arises from the neural crest cells  During fetal development the migration of adrenocortical and medullary cells can result in accessory or ectopic tissue
08/17/2025 Dr. Samuel L. 5 ANATOMY  Paired retroperitoneal organs  Weigh 4-5g each  Arterial supply  Superior adrenal aa- from inf phrenic aa  Middle adrenal aa- from abd aorta  Inferior adrenal aa- from renal aa  Venous return  Rt- short & drains directly to IVC  Lt- into Lt renal vv
08/17/2025 Dr. Samuel L. 6 PHYSIOLOGY
08/17/2025 Dr. Samuel L. 7 Synthesis & metabolism of catecholamines
08/17/2025 Dr. Samuel L. 8 PRIMARY HYPERALDOSTERONISM  Hypertension, hypokalemia, and alkalosis  From a treatment standpoint, the subtypes of primary hyperaldosteronism thus can be divided into two groups:  Surgically manageable  Medically treated
08/17/2025 Dr. Samuel L. 9 Epidemiology  M:F- 1:2  30-50 yrs  5-13 % of hypertensive pts;  20% in those with resistant HTN
08/17/2025 Dr. Samuel L. 10 Clinical & pathologic Features Clinical features  Hypertension with or without hypokalemia  HTN is moderate to severe and resistant to medical mx  Headache, fatigue, muscle weakness…  Peripheral edema is rare due to ‘aldosterone escape’  Significant cardiac and metabolic alterations Pathologic features  Solitary, unilateral , and small (<2cm)  Characteristic golden yellow appearance
08/17/2025 Dr. Samuel L. 11 Diagnosis  Elevated aldosterone with suppressed renin levels  Elevated PAC levels in combination with PAC:PRA ratio  Saline suppression test Failure to suppress PAC below 10 ng/ml and Urinary aldosterone secretion greater than > 12 ug/24hr with urinary Na excretion more than 200 mEq /24hr PAC:PRA > 20-30 in the setting of PAC >15-20 ng/dl
08/17/2025 Dr. Samuel L. 12 Localization  CT - a unilateral 1- to 2-cm hypo dense lesion with a normal contralateral adrenal gland suggests aldosteronoma  MRI  NP-59 Scan  Adrenal venous sampling  First confirm proper cannulation  Then compare aldosterone levels
08/17/2025 Dr. Samuel L. 13 TREATMENT
08/17/2025 Dr. Samuel L. 14 TREATMENT SURGICAL- laparoscopic Vs Open  Pre-op rx with spironolactone reduces surgical risks  Pre-op ARBs also reduce risk of postop hypoaldosteronism Medical  Also in poor surgical candidates  Spironolactone, eplerenone  Dexamethasone- for glucocorticoid suppressible
08/17/2025 Dr. Samuel L. 15 POST-OP OUTCOMES  K levels normalizes in 95% pts immediately  HTN improves in 75% within a month  1/3 will no longer require medication  2/3 require reduced dose  There is association between increased age and longer duration of HTN with persistent post-op HTN
08/17/2025 Dr. Samuel L. 16 Management Algorithm
08/17/2025 Dr. Samuel L. 17 CUSHING SYNDROME Cushing’s syndrome refers to a complex of symptoms and signs resulting from hypersecretion of cortisol regardless of etiology. Cushing’s disease refers to a pituitary tumor, usually an adenoma, which leads to bilateral adrenal hyperplasia and hypercortisolism • Rare disease (10/1mil) • M:F ratio is 1:8 • Most are sporadic
08/17/2025 Dr. Samuel L. 18 CLINICAL FEATURES
08/17/2025 Dr. Samuel L. 19 LAB STUDIES SCREENING  Overnight dexamethasone suppression test  48 hr./low-dose dexamethasone suppression test  Late-night salivary cortisol measurement  Urinary cortisol
08/17/2025 Dr. Samuel L. 20 EVALUATION OF THE UNDERLYING CAUSES  Plasma ACTH  ACTH less than 2 pmol/l (10 pg/ml) indicate ACTH-independent Cushing’s syndrome  ACTH greater than 4 pmol/l (20 pg/ml)  High dose dexamethasone suppression  Pituitary MRI  Bilateral petrosal vein sampling  Chest and abdominal CT
08/17/2025 Dr. Samuel L. 21
08/17/2025 Dr. Samuel L. 22 Management  MEDICAL  For perioperative control of hypercortisolism or  When surgery is not feasible  Metyrapone, ketoconazole, and mitotane  SURGERY  Pituitary adenoma- TSS, *bilateral laparoscopic adrenalectomy  Ectopic TSH secreting tumors-resection, *medical therapy or *bilateral adrenalectomy  Adrenal causes- adrenalectomy (unilateral or bilateral; open or laparoscopic)
08/17/2025 Dr. Samuel L. 23 PHEOCHROMOCYTOMA  Arise from the cells of the adrenal medulla  MEN2A, MEN2B, VHL disease, NF1  10 percent tumor  peak incidence in the fourth and fifth decades  no gender predilection
08/17/2025 Dr. Samuel L. 24 Clinical Features  Classic triad of headaches, palpitations, and extreme hypertension  Paroxysmal spells  In 0.1-0.2 % of hypertensive pts  Myocardial ischemia  Raynaud’s type phenomenon  Other sxs : nausea, lassitude, heat intolerance, anxiety, abdominal pain, pallor, fever, or glucose intolerance
08/17/2025 Dr. Samuel L. 25 Diagnosis  Identification of the classic signs  24 hr. urine metanephrines and fractionated catecholamines  Plasma free metanephrines  Localization  CT of abdomen & Pelvis-heterogeneous, central necrosis  MRI- hyper intense ‘bright white’ signal on T2  MIBG scan-
08/17/2025 Dr. Samuel L. 26 Pre-op management  Alpha blockage- phenoxybenzamine  For a minimum of 1-3 wks  Orthostatic hypotension & ‘stuffy nose’  Ca2+ channel blockers- nicardipine  Volume expansion- fluids, high salt diet  Beta blocker- as needed  Metyrosin - in refractory HTN/ Tachycardia
08/17/2025 Dr. Samuel L. 27 Intra-op mx  The most volatile BP swings occur with induction of anesthesia  With occlusion of the adrenal vein, the pt may rapidly vasodilate  Excellent communication should be maintained b/n the surgeon & anesthesiologist  Physical manipulation of the tumor should be minimized  RX- Adrenalectomy
08/17/2025 Dr. Samuel L. 28 Special populations Pregnant  Supine HTN  MRI is the best imaging choice  Follow with meds until safe GA for delivery  CS with tumor excision Children  HTN is more often sustained  Tendency to be bilateral & extra- adrenal  Malignancy is less frequent
08/17/2025 Dr. Samuel L. 29 Malignant Pheochromocytoma  There are no definitive histologic criteria defining malignant pheochromocytomas  Malignancy is usually diagnosed with evidence of invasion into surrounding structures or distant metastases  Mets: to bone, liver, regional lymph nodes, lung, and peritoneum  Treatment  Resection if feasible  External-beam radiation for un resectable lesions  Therapeutic 131 I-MIBG irradiation  Chemotherapy
08/17/2025 Dr. Samuel L. 30 Adrenocortical cancer  Rare neoplasms (2 per 1 million in the world)  Bimodal age distribution  The majority are sporadic  ~ 50% of adrenocortical cancers are nonfunctioning  Functional tumors secrete cortisol (30%), androgens (20%), estrogens (10%), aldosterone (2%); or multiple hormones (35%)  CF: rapid onset of Cushing’s syndrome accompanied by virilizing features  Enlarging abdominal mass, pain
08/17/2025 Dr. Samuel L. 31 Adrenocortical cancer DIAGNOSTIC TESTS  Lab tests  CT/MRI:  tumor heterogeneity, irregular margins, and the presence of hemorrhage and adjacent LAP or liver metastases  moderately bright signal intensity on T2-weighted images  significant lesion enhancement, and slow contrast washout  evidence of local invasion into adjacent structures  CT of chest & pelvis: staging
08/17/2025 Dr. Samuel L. 32 Adrenocortical cancer Pathology : criteria to predict malignancy  nuclear grade III or IV;  mitotic rate greater than 5 per 50 high- power fields;  atypical mitoses;  clear cells comprising 25% or less of the tumor;  a diffuse architecture;  microscopic necrosis;  invasion of venous, sinusoidal, and capsular structure Tumors with four or more of these criteria were likely to metastasize and/or recur
08/17/2025 Dr. Samuel L. 33 Adrenocortical cancer
08/17/2025 Dr. Samuel L. 34 Treatment SURGERY  Open adrenalectomy is the procedure of choice  R0 resection must be the goal  Enbloc resection with contiguous structures  Surgical debulking CHEMOTHERAPY  Etoposide, cisplatin, doxorubicin, paclitaxel +_ mitotane RADIOTHERAPY –incomplete resection, palliation of bone mets
08/17/2025 Dr. Samuel L. 35 INCIDENTALOMA  These are adrenal lesions discovered during imaging performed for unrelated reasons  Frequency: 5.9% of autopsies & 4.3 % from images  Although non-functional by definition , most of them may be sub clinically functioning
08/17/2025 Dr. Samuel L. 36
08/17/2025 Dr. Samuel L. 37 Screening for subclinical disease  Subclinical Cushing’s Syndrome  Ranges from slightly attenuated diurnal cortisol rhythm to atrophy of the contralateral gland  Do dexamethasone suppression test  Subclinical Pheochromocytoma  Refers to totally asymptomatic adrenal incidentaloma that histologically proves to be pheochromocytoma  24 hr urine metanephrine & VMA, or fractionated urinary catecholamine  Subclinical Primary Aldosteronism  Pt with adrenaloma who is normotensive or hypertensive with normokalemia
08/17/2025 Dr. Samuel L. 38 Screening for subclinical disease  Screening for adrenal Ca  4-25 % harbor Ca  Imaging findings  CT-ragged tumor with stippled calcifications and with areas of necrosis; enlarged LN or local invasion  MRI-heterogeneously increased, early T2-weighted signal, weak and late enhancement after gadolinium  FNAB has limited role
08/17/2025 Dr. Samuel L. 39 Management: Surgery Vs Follow-up • Surgery Lab evidence for sub clinically functioning tumor Associated metabolic features Evidence of primary or solitary metastatic ca • Follow-up: yearly for 5-10 yrs.
08/17/2025 Dr. Samuel L. 40 Miscellaneous adrenal masses ADRENAL METASTASES  From the lung , melanoma, breast, kidney, and GI neoplasms  ~50% are functional  Appropriate biochemical evaluation prior to further imaging, bx or rx  Imaging: CT with contrast, MRI  The definitive dx of malignancy requires percutaneous bx or surgical pathology
08/17/2025 Dr. Samuel L. 41 Management of adrenal metastases Appropriate mx depends on: Type & extent of primary malignancy DFI Patient comorbidity Resection of isolated adrenal metastases may offer a survival benefit.
08/17/2025 Dr. Samuel L. 42 Miscellaneous adrenal masses ADRENAL HEMORRHAGE Causes  trauma, surgery, anticoagulant rx, septicemia or tumor  Increased ACTH  Adrenal medullar venous thrombosis ADRENAL CYSTS  Benign or malignant(7%)  Endothelial cysts, epithelial cysts  Pseudocysts can arise from hemorrhage  Small, asymptomatic or non- functioning- can be followed  Size >6cm, symptomatic, functioning or suspected malignancy- surgery
08/17/2025 Dr. Samuel L. 43 Miscellaneous adrenal masses  Lymphangioma  Pseudocysts  Paracytic infections  Myolipoma Surgery  Symptomatic  Suspicion of malignancy  Hydatid cyst
08/17/2025 Dr. Samuel L. 44 Techniques of adrenalectomy  OPEN Vs LAPAROSCOPIC  OPEN ADRENALECTOMY Anterior approach Posterior approach Lateral approach Thoraco -abdominal approach
08/17/2025 Dr. Samuel L. 45
08/17/2025 Dr. Samuel L. 46 ANTERIOR APPROACH • Midline incision or bilateral subcostal Incision • Access to Rt adrenal • Mobilize the liver medially; reflect hepatic flexure of the colon • Kocher maneuver & exposure of RP • Gerota’s fascia is incised • Mobilize the sup & lat surfaces first • Divide the adrenal vein • Access to Lt adrenal • Medial visceral rotation • Via lesser sac by division of the gastrocolic ligament
08/17/2025 Dr. Samuel L. 47 Complications of adrenalectomy  Infection  Bleeding  Hemodynamic instability  Adrenal insufficiency
08/17/2025 Dr. Samuel L. 48 Postoperative care  Depends on the operative approach, extent of resection, and functional or nonfunctional nature of the tumor  Pheochromocytoma  ICU for a minimum of 4 hrs  a-blockers: discontinue  B-blockers- if started pre-op, it should be continued & weaned post-op  Aldosteronoma  DC all antihypertensive meds except b-blockers  DC spironolactone  Check serum K the next morning  Follow BP as an outpatient  Cushing’s syndrome  Continue glucocorticoids with subsequent dose tapering  Mineralocorticoid supplementation after bilateral adrenalectomy
08/17/2025 Dr. Samuel L. 49 REFERENCES