Adrenal Glands Flashcards
Where is the adrenal medulla derived from?
neuroectoderm
What is the blood supply of the adrenal glands?
- superior suprarenal artery —- from phrenic artery
- middle suprarenal artery —- from aorta
- inferior suprarenal artery —- renal artery
What is the venous drainage of the adrenal glands?
on the right: IVC
on the left: left renal vein
LIKE TESTICULAR
What does the adrenal medulla secrete?
Catecholamines
What are the secretions of the adrenal cortex?
zona glomerulosa —- mineralocorticoids
zona fasciculata —- glucocorticoids
zona reticularis —- sex hormones
what is the origin of pheochromocytoma?
chromaffin cells from adrenal medulla
neuroectoderm
pheochromocytoma has a rule of?
10%
What are the features of a suspected malignant pheochromocytoma?
- necrosis or hemorrhage
- high KI-67 positive cells ad size of tumor
- increased PASS >4
- capsular or vascular invasion (like follicular thyroid carcinoma)
- nuclear DNA ploidy ad increased NSE
What are the syndromes associated with familial pheochromocytoma?
- Von Recklinghausen disease (cafe au lait spots)
- Von-Hippel-Lindau syndrome
- MENIIa or MENIIb
How do we suspect pheochromocytoma in young age?
persistent or paroxysmal hypertension (90%)
sympathetic overactivity
DD of pheochromocytoma?
- hyperthyroidism (exclude by hormonal assay)
- anxiety status
- cardiac conditions
- carcinoids (functioning)
How do u diagnose pheochromocytoma in a suspected case?
Laboratory
- Vanil Mandelic acid (VMA) in urine >7mg/24hrs
- urinary noradrenaline or other catecholamines (MORE SPECIFIC)
Radiological
- Xray (if calcified)
- ultrasound & IVU
- SPECT scan (search for gamma rays and identifies neuroendocrine cells)
- MRI
What method of investigation is used to confirm the presence of cells originating from neuroectoderm in extra adrenal locations?
Iodine Labelled Metaiodobenzylguanidine (I, MIBG)
What’s the most important preoperative procedure?
Control hypertension
- alpha-blocker given 4 weeks prior to surgery to control hypertension
- beta-blocker is given only after patient is fully alpha-blocked and given 1 week before surgery
What is used to control hypertension inside the surgery?
IV sodium nitroprusside
how should adrenal cortical tumors be managed & what are the investigations used?
> 6cm requires resection
- US abdomen
- CT scan
- hormonal assay
Houns field unit density is considered positive for pheochromocytoma when?
density is > 18
What is the only indication of biopsy in pheochromocytoma?
non functioning
or metastasis to adrenals
How is the adrenal incindentaloma treated?
- if functional treat and resect
- if non-functional but >4cm - >6cm and rapidly increasing in size, surgical resection
- if non-functional and <4cm, should be followed up after 6, 12, and 24 months by MRI and hormonal evaluation
How should pheochromocytoma be managed intraoperatively?
- careful anesthetic management
- adrenal vein should be ligated first
- avoid breaks in capsule of tumor
- careful handling & hemodynamic monitoring
What postop care should be done?
- proper monitoring to avoid hypovolemia & hypoglycemia
- specimen should be sent for BICHROMATE STAINING
- steroids must be given (if bilateral)
- screen for recurrence every 6-12 months radiologically & by urinary VMA
How is a malignant pheochromocytoma managed?
- early: adrenalectomy
- advanced: debulking
What is the aetiology of incindentalomas?
- non functioning adenomas
- Cushing’s adema, pheochromocytoma or Conn’s adenoma
- Ganglioneuroma, myelolipoma or adrenal cyst
- adrenocortical carcinoma
- secondaries
What investigations should be done in a suspected cortisol producing neoplasm?
- overnight dexamethasone suppression test
- 24 hour urinary cortisol excretion assay
- ACTH to differentiate between adrenal causes & pituitary causes
What investigations should be done in a suspected cortisol producing neoplasm?
- overnight dexamethasone suppression test
- 24 hour urinary cortisol excretion assay
- ACTH to differentiate between adrenal causes & pituitary causes
What investigations should be done in suspected pheochromocytoma?
- 24 hour urinary excretion of catecholamines & VMA
- serum metanephrines
What investigations should be done incase of suspected hyperaldosteronism?
- HTN+hypokalemia
- serum potassium, renin & aldosterone
- 24h urine aldosterone level
