Adrenal Mass, Incidental - Core/Disease

Question 1

What is the initial workup for an adrenal incidentaloma?

Answer 1

• H&P
  
  • Prior malignancies
  • S/sx of adrenal hormone excess
  • Family hx of adrenal tumors
• Review of imaging and potentially CT adrenal protocol if not already done
• Biochemical workup

Question 2

What symptoms are associated with each type of functional adrenal tumor?

Answer 2

Pheochromocytoma

• HTN, tachycardia, diaphoresis, syncope

Aldosterone secreting

• HTN, hypokalemia

Cortisol secreting

• HTN, central weight gain, striae, hyperglycemia, depression, hirsutism

Adrogen secreting

• Hirsutism
• Virulization
• Acne

Question 3

What are concerning findings on CT adrenal protocol for potential malignancy?

Answer 3

• >10 Hounsfield Units
• <60% Washout
• Irregular border
• Size >4cm
• Invasion to surrounding structures
• Lymphadenopathy

Question 4

What is involved in the biochemical workup for adrenal incidentaloma?

Answer 4

Pheochromocytoma

• 24-hour urine metanephrines OR
• Plasma free metanephrines

Cushing’s Syndrome (adrenal, pituitary, or ectopic)

• 24-hour urine cortisol (I would start here)
• 2-3 midnight salivary cortisols
• 1 mg overnight dexamethasone suppresion test
  
  • AM cortisol >5 ug/dL is abnormal

Hyperaldosteronism

• Plasma aldosterone and plasma renin levels
  
  • aldosterone:renin > 20 AND aldosterone >15 ng/dL is abnormal
• Potassium lab

Adrogen producing

• DHEA-S
• Testosterone

Question 5

What are indications for surgical excision of an adrenal incidentaloma?

Answer 5

• >4 cm
• Functional
• Imaging with concerning findings
  
  • >10 Hounsfield Units
  • <60% washout in delayed imaging
  • Irregular borders
  • Invasion to surrounding structures
  • Lymphadenopathy

Question 6

In a patient with pheochromocytoma, what needs to be done prior to surgery?

Answer 6

Alpha-adrenergic blockade

• 10-14 days prior to OR
• Phenoxybenzamine or doxazosin

Beta-blockers can then be used after the initiation of alpha-blockers

Question 7

In a patient with Cushing Syndrome, what needs to be done prior to surgery?

Answer 7

• Stress dose steroids

Question 8

In a patient with hyperaldosteronemia, what needs to be done prior to surgery?

Answer 8

Give a competitive aldosterone anatagonist

• Spironolactone or eplerenone
• Treats HTN and hypokalemia

Question 9

When is open adrenalectomy preferred over minimally-invasive?

Answer 9

• Tumors >8 cm
• Tumors with obvious imaging findings consistent with malignancy

Question 10

Key steps to lap left adrenalectomy

Answer 10

1. Place patient in right lateral decubitus position, ipsilateral side up.
2. Obtain laparoscopic access.
3. Mobilize splenic flexure of colon.
4. Divide lateral peritoneal attachments of spleen and lienophrenic ligament.
5. Reflect spleen medially and mobilize pancreatic tail.
6. Bluntly create a plane medial to adrenal gland and lateral to aorta.
7. Dissect and divide the inferior phrenic vessels and central adrenal vein.
8. Mobilize adrenal gland by dividing inferior and lateral attachments.
9. Remove adrenal gland from abdomen.
10. Inspect suprarenal fossa for hemostasis.
11. Close port sites.

Question 11

Key steps to lap right adrenalectomy

Answer 11

1. Place patient in left lateral decubitus position, ipsilateral side up.
2. Obtain laparoscopic access.
3. Retract right lobe of liver medially.
4. Open peritoneum overlying adrenal gland inferior to superior.
5. Bluntly create a plane medial to adrenal gland and lateral to vena cava.
6. Dissect and divide the central adrenal vein (clip or linear stapler).
7. Mobilize adrenal gland by dividing inferior and lateral attachments.
8. Remove adrenal gland from abdomen.
9. Inspect suprarenal fossa for hemostasis.

Question 12

You are having a difficult time locating the adrenal gland during surgery. What adjunct can you use to help you?

Answer 12

• Intraoperative US

Question 13

What action do you take if adrenal cancer is found during laparoscopic adrenalectomy?

Answer 13

• This necessitates conversion to open procedure

Question 14

Key steps to an open adrenalectomy

Answer 14

• Place supine; midline or subcostal incision
• Left
  
  1. Mobilize splenic flexure
  2. Mobilize spleen and tail of pancreas
  3. Inferior phrenic and central adrenal vessels are dissected and divided
  4. Complete removal of adrenal gland
• Right
  
  1. Mobilize hepatic flexure
  2. Perform partial Kocher maneuver
  3. Mobilize right liver by dividing triangular ligament
  4. Mobilize lateral and inferior margins of adrenal
  5. Dissect and divide central adrenal vein
  6. Complete removal of adrenal gland

Question 15

Postoperative management of adrenalectomy

Answer 15

• In aldosteronoma
  
  • Stop K supplements
  • Wean anti-hypertensives
• In pheochromocytoma
  
  • Monitor in ICU initially for hypotension and hypoglycemia
  • Stop alpha-blockers
  • Wean beta-blockers
• In Cushing Syndrome
  
  • Steroid taper to physiologic doses

Question 16

What are you plans for an adrenal incidentaloma that is non-functioning, <4cm, and has no concerning features on imaging?

Answer 16

• Repeat CT imaging and functional workup in 1 year.
• Excise if:
  
  • Growing
  • Change in imaging features
  • Gain of function