The document discusses adrenal incidentaloma, which are clinically inapparent adrenal masses incidentally discovered on imaging. It covers the history, anatomy, epidemiology, evaluation for malignancy including tumor size and imaging features, assessment of hormonal function, and management. Evaluation for hormonal function includes testing for cortisol hypersecretion using tests like the overnight low-dose dexamethasone suppression test and screening for pheochromocytoma or primary aldosteronism if indicated. Imaging features that suggest malignancy include a size greater than 4 cm, irregular shape, necrosis or hemorrhage, and delayed washout on contrast CT or MRI.

1. ADRENAL INCIDENTALOMA
Dr. ZAHID IQBAL MIR
MBBS, MS, DNB
 Incidentally discovered adrenal mass
 Clinically inapparent adrenal mass

2. HISTORY
ANATOMY & PHYSIOLOGY
INTRODUCTION
EPIDEMIOLOGY
EVALUATION OF MALIGNANCY
SIZE
IMAGING PHENOTYPE
BIOPSY
ASSESSMENT OF FUNCTION OF ADRENAL
MANAGEMENT
SUMMARY & RECOMMENDATION
DISCUSSION

3. HISTORY
Bartholomaeus Eustachius – first to describe the organs
in the mid 16th century
Thomas Addison - adrenal insufficiency
Discovery and isolation of cortisol from
adrenal (1930s) & its use to treat
rheumatoid arthritis - 1950 Nobel Prize
Edward Kendall, Philip Hench, and Tadeus
Reichstein

4. ◦ The latter part of the 20th century witnessed a rapid
transformation in our understanding and treatment of
adrenal disorders led by pioneers such as Jerome Conn,
Lawson Wilkins, Grant Liddle, and Earl Sutherland
1990)

5. ANATOMY
◦ 4 to 5 g each
◦ Size from 4 to 6 cm in length and
2 to 3 cm in width
◦ Right adrenal gland location -
Pyramid-shaped ("witch's hat")
and lies above the upper pole of
the right kidney, between the liver
and the diaphragm.
◦ Left adrenal gland location -
between the kidney and aorta,
near the tail of the pancreas and
the splenic artery.

6.  Superior suprarenal
arteries- from inferior
phrenic arteries,
 Middle suprarenal artery
– from the aorta.
 Inferior suprarenal renal
arteries –from the
adjacent renal artery.
Other adjacent vessels also may supply branches to the adrenal gland-
the intercostal arteries, the left ovarian artery, and the left internal spermatic arteries

7. Venous drainage of the left adrenal gland :
2 to 3 cm in length.
Drains into either the left renal vein or the left inferior
phrenic vein.
Venous drainage of the right adrenal gland :
enters the posterior segment of the inferior vena cava at a
45° angle.
less than 1 cm in length.
Rarely, aberrant veins may drain into the right hepatic vein
or right renal vein.
Small direct hepatic branches draining from the posterior aspect of the
liver into the vena cava may join the adrenal vein and can be torn
during adrenalectomy

8. Physiology

9. Mass lesion >1 cm in diameter, serendipitously
discovered on radiologic examination performed
for seemingly unrelated causes
Is it malignant?
Is it functioning?
N Engl J Med. 2007;356(6):601.

10. PREVALENCE – UNILATERAL
◦ 61,054 abdominal CT scans performed from 1985 to
1990, incidentaloma >1 cm - 0.4 % of all CT scans)
◦ Higher resolution scanners – 4.4 %
◦ Obese, diabetic, and hypertensive patients – Higher
◦ Older population - 10%
Surgery. 1991 Dec;110(6):1014-21
J Endocrinol Invest. 2006;29(4):298.
Eur J Endocrinol. 2011;164(6):851.

11. ◦ > 60 years – 10%
◦ Autopsy studies - 2 % (1-9%)
◦ In a series of 739 autopsies, 2 mm - 4 cm in size – 9
% of normotensive and in 12 % of hypertensives.
Eur J Endocrinol. 2011;164(6):851.
Acta Med Scand. 1968;184(3):211
Eur J Endocrinol.2016;175:G1–G34

12. ◦ Bilateral masses in 10 to 15 % of cases
◦ Seen with:
Horm Res. 1997;47(4-6):279 J Clin Endocrinol Metab. 1998;83(1):55
PREVALENCE – BILATERAL
 Metastatic disease  Hemorrhage  Amyloidosis
 Congenital adrenal
hyperplasia
 Infection (tuberculosis,
fungal)
 Infiltrative disease of
the adrenal
 Cortical adenomas  Pheochromocytoma  B/L macronodular
adrenal hyperplasia
 Lymphoma  Primary aldosteronism  ACTH dependent
Cushing’s

13. Adrenal lesion %age of total(n=2005)
Metabolically active 11.2%
Cortisol producing adenoma 5.3%
Aldosterone producing
adenoma
1.0%
Pheochromocytoma 5.1%
Malignant 7.2%
Adrenocortical carcinoma 4.7%
Metastasis 2.5%
Total potentially surgical lesion 18.4%
Endocrinol Metab Clin North Am 29(1):159–185, 2000
N Engl J Med 356(6):601–610, 2007
“Incidental” does not mean insignificant.

14. Sign & symptoms of hormonal imbalance
Substantial weight gain
Centripetal obesity
Easy bruising
Severe hypertension
Diabetes
Virilization
Proximal muscle weakness
Fatigue

15. EVALUATION OF MALIGNANCY
Primary adrenal carcinoma in patients - 2 to 5 %;
Non adrenal metastases to the adrenal gland - 0.7 to
2.5 %
Whether the tumor is benign or malignant?
- Size
- Imaging characteristics
- FNAC ?

16. Size is predictive of malignancy.
Adrenocortical carcinomas – 90 % being more than 4 cm in
diameter
Smaller the adrenocortical carcinoma at the time of
diagnosis - better the overall prognosis
Surgical removal of unilateral masses > 4 cm should be
considered to avoid missing adrenal carcinomas, particularly
in younger patients
Horm Res. 1997;47(4-6):279.
Surgery. 1983;94(6):926.
SIZE

17. Not only size ?
In a retrospective, single center cohort of 4085 patients with
adrenal tumors, 17 % >=4 cm,
• 31%- adrenocortical adenomas
• 22%-pheochromocytomas
• 16%-other benign tumors
• 13%-adrenocortical carcinomas
• 18%-other malignant tumors
Mayo Clin Proc Innov Qual Outcomes. 2018;2(1):30. Epub 2017 Dec 21.
Predictors of malignancy
older age at diagnosis
male sex
non incidental mode of discovery
larger tumor size
higher unenhanced CT attenuation

18. IMAGING
Ultrasonography :
Suboptimal modality
Less sensitive in identifying left-sided adrenal lesions
than those in the right gland.
• On the right, the IVC and liver provide a better window
to the adrenal gland on ultrasonography, whereas on
the left the adrenal gland can be overlooked or mistaken
as part of the splenic, pancreatic, paraaortic lymphatic,
or gastric anatomy.

19. Unenhanced Computed Tomography:
First, single best, and most easily interpreted test
for intracellular lipid and therefore can diagnose
adrenal adenoma in more than 70% of cases.
Low attenuation (<10 HU) on unenhanced CT
corresponds to high intracytoplasmic lipid content
and is diagnostic for an adrenal adenoma
J Clin Endocrinol Metab. 2005;90(2):871

20. Delayed Enhanced Computed Tomography
Adenomas typically exhibit rapid contrast medium
washout, whereas non adenoma have delayed
contrast material washout.
• 10 minutes after administration of contrast, an
absolute contrast medium washout of more than 50
was reported to be 100 % sensitive and specific for
adenoma when patients with adenomas were
compared with carcinomas, pheochromocytomas,
metastases
J Clin Endocrinol Metab. 2005;90(2):871

21. MRI
◦ Follow up imaging with MRI avoids the radiation exposure
repeated CT imaging.
Conventional spin echo MRI - most frequently used.
• can distinguish benign adenomas from malignancy and
pheochromocytoma
On gadolinium-diethylene triamine pentaacetic acid
(DTPA)-enhanced MRI, adenomas demonstrate mild
enhancement and a rapid washout of contrast, while
malignant lesions show rapid and marked enhancement
a slower washout pattern
MR with chemical shift imaging (CSI) accurately
distinguishes adrenal adenomas from non-adenomas
on their elevated amounts of intracytoplasmic fat

23. Positron emission tomography (PET) with
either fludeoxyglucose F 18 (FDG) or 11 C
metomidate (MTO) :
Helpful in prior history of malignancy or
when unenhanced CT attenuation or
washout is inconclusive or suspicious of
malignancy

24. TYPICAL IMAGING FEATURES
BENIGN ADENOMA
 Round
 Homogeneous density
 Smooth contour
 Sharp margin
 < 4cm , unilateral
 Low unenhanced CT attenuation values (≤10 HU)
 Rapid contrast medium washout
 Isointense with liver on both T1 and T2 weighted MRI
sequences
 Chemical shift evidence of lipid on MRI

26. PHEOCHROMOCYTOMAS
 Increased attenuation on unenhanced CT (>20 HU)
 Increased mass vascularity
 Delay in contrast medium washout
 High signal intensity on T2-weighted MRI
 Cystic and hemorrhagic changes
 Variable size and may be bilateral

28. ADRENOCORTICAL CARCINOMA
Irregular shape and inhomogeneous nature
Tumour calcification
>4cm, Unilateral
High unenhanced CT attenuation values (>20 HU)
Inhomogeneous enhancement on CT with IV contrast
Delay in contrast medium washout
Hypointense compared with liver on T1and high to
intermediate signal intensity on T2-weighted MRI
High standardized uptake value on FDG-PET-CT study
Evidence of local invasion or metastases

30. ADRENAL METASTASIS
 Irregular shape and inhomogeneous nature
 Tendency to be bilateral
 High unenhanced CT attenuation values (>20 HU) and
enhancement with IV contrast on CT
 Delay in contrast medium washout
 Isointense or slightly less intense than the liver on and
high to intermediate signal intensity on T2-weighted
MRI
 High standardized uptake value on FDG-PET-CT study

31. Unenhanced (A) and enhanced (B) axial CT
images from a 54-year-old woman who
presented with shortness of breath. A
chest CT scan had been performed to
screen for pulmonary embolus and
incidentally detected bilateral adrenal
masses (arrows). In a subsequent
abdominal CT scan, the right adrenal mass
measured 11.7 × 8.6 × 9.1 cm with an
unenhanced CT attenuation of 35 HU. The
left adrenal mass measured 5.4 cm in
maximum diameter and had an
unenhanced CT attenuation of 39 HU.
With contrast administration, both adrenal
masses enhanced markedly and
inhomogenously (B), and both had slow
contrast washout (<50% at 10 minutes).
The abdominal CT scan also detected a
large right renal mass, which proved to be
renal cell carcinoma. After excluding
pheochromocytoma, biopsy of the right
adrenal mass documented metastatic
renal cell carcinoma.

32. FNAC
Cytology from a specimen obtained by FNA cannot
distinguish a benign cortical adrenal mass from the less
common adrenal carcinoma. It can, however, distinguish
between an adrenal tumor and a metastatic tumor
Possibility of pheochromocytoma should always be ruled out
by biochemical testing before FNA biopsy is undertaken
Arch Surg. 2009;144(5):465
Surgery. 2009;146(6):1158.

33. Limitations of adrenal biopsy :
Modern imaging in the context of clinical characteristics
affords superb diagnostic capabilities
Histologically, adenomas cannot be reliably
from adrenal carcinomas
Adrenal biopsy is not without risk
Adrenal biopsy should be pursued only when limitations
of imaging have been reached and when the physician
and patient are certain that the result of biopsy will
influence management

35. Assessment of Function of Adrenal
Masses
Metabolic testing for all adrenal incidentalomas.
> 10% are metabolically active
Current practice is to test all new adrenal masses for
cortisol and catecholamine hypersecretion.
In patients with a history of hypertension, aldosterone
hypersecretion should also be assessed

36. While most adrenal incidentalomas are nonfunctional, 10
- 15 % secrete excess amounts of hormones
Three forms of adrenal hyperfunction :-
Subclinical glucocorticoid secretory autonomy
(subclinical Cushing's syndrome)
Pheochromocytoma if the unenhanced computed
tomography (CT) attenuation is >10 HU
Primary aldosteronism if the patient is hypertensive or
has hypokalemia
EVALUATION FOR HORMONAL SECRETION
J Clin Endocrinol Metab. 2000;85(2):637.
Eur J Endocrinol. 2009;161(4):513

37. 1. Testing for Cortisol hypersecretion
5% to 8% of adrenal incidentalomas produce excessive
glucocorticoids (Barzon et al., 2003; Young, 2000).
Three first line tests are available to screen patients with
incidentalomas for Cushing syndrome:
LD-DST
Late night salivary cortisol test
 24- hour UFC evaluation.

38. LD-DST or the late-night salivary cortisol test to
screen patients with adrenal incidentalomas as part of
a complete endocrinologic evaluation is
recommended (Nieman et al., 2008).
Verify that the patient is not using exogenous
before testing.
Suppressed or low morning plasma ACTH should be
confirmed prior to resection in patients with clinically
significant hypercortisolemia and adrenal mass who
elect to proceed with surgery (Fassnacht et al., 2016).

39. Overnight Low-Dose Dexamethasone
Suppression Test
 1 mg of dexamethasone given between 11 PM and 12 AM
The next morning, serum cortisol is measured between 8
AM and 9 AM.
 In patients without hypercortisolemia, the cortisol level
should be suppressed below 5 μg/dL (140 nmol/L).
 Failure to suppress cortisol levels after low dose
dexamethasone administration is indicative of Cushing
syndrome
 50% false-positive rate in women using OCP’s because the
contraceptives increase total cortisol levels by raising the
patient's cortisol-binding globulin concentrations

40. Drugs That Affect Testing
Accelerate Dexamethasone Metabolism by Induction of Cyp3a4
Phenobarbital, Phenytoin, Carbamazepine, Primidone, Rifampin,
Rifapentine, Ethosuximide, Pioglitazone
Impair Dexamethasone Metabolism by Inhibition of Cyp3a4A
Prepitant, Fosaprepitant, Itraconazole, Ritonavir, Fluoxetine,
Diltiazem, Cimetidine
Increase Cortisol binding Globulin and May Falsely Elevate
Cortisol Results
Estrogen, Mitotane
Increase Urine Free Cortisol Results
Carbamazepine, Fenofibrate
http://medicine.iupui.edu/flockhart/table.htm.

41. Late night salivary cortisol
Measurements of cortisol in saliva collected between 11
PM and midnight or at bedtime should not exceed 145
ng/dL when the liquid chromatography–tandem mass
spectrometry assay is used (Nieman et al., 2008).
Unacceptably high false-positive rates may occur in
patients with depression, altered sleep patterns, and
chronic illness, because normal circadian variation in
cortisol levels can be altered in these individuals.
Tobacco use can affect salivary cortisol levels and should
be avoided on the day of testing (Nieman et al., 2008)

42. 24-Hour Urinary Free Cortisol (UFC)
Evaluation
24 hour direct measurement of free bioavailable
cortisol.
Patient is instructed to discard the morning's first
voided urine and begin to collect all subsequent
voided samples. The last sample that is collected is
the first morning's void of the following day.
Collection and analysis of two separate samples
Creatinine levels in the collection must be checked
to verify completeness of the collection.

43. Subclinical glucocorticoid secretory autonomy
a.k.a Subclinical Cushing's syndrome or autonomous
cortisol secretion
Cortisol secretion without clinical manifestations of
Cushing's syndrome
Secrete cortisol independently of corticotropin
Cortisol secretion can be under the control of one or
more aberrant hormone receptors in patients with U/L
adenomas or incidental B/L macronodular adrenal
hyperplasia

44. Clinical manifestations :
May have ffects of continuous ACTH independent cortisol
secretion, including hypertension, dyslipidemia, diabetes,
weight gain, osteoporosis, and evidence of atherosclerosis
Atrial fibrillation - more common when compared with
those with nonsecreting adenomas
Diagnosis - Subclinical Cushing's syndrome should be
ruled out by obtaining a baseline serum
dehydroepiandrosterone sulfate and performing the 1 mg
overnight DST
Overnight DST should not be performed if the patient is
thought to have a pheochromocytoma based upon the
initial imaging study. — catecholaminergic crisis

46. Hypersecretion of aldosterone by adrenal masses is
extremely rare - 1% of adrenal adenomas responsible
for Conn syndrome
5% of newly hypertensive patients may harbor an
aldosterone secreting adenoma (Rossi et al., 2006).
low serum potassium level - screening tool to assess for
the presence of aldosterone hypersecretion.
2. Testing for Aldosterone hypersecretion
 Testing of hypertensive patients with adrenal lesions
for hyperaldosteronemia is clinically recommended.

47. Screening test of choice for Conn syndrome is the ratio of
morning plasma aldosterone (ng/dL) to renin (ng/mL/h).
• Sample should be drawn in morning 8AM – 10 AM
An ARR of 20 (some suggest 30) along with a concomitant
aldosterone concentration above 15 ng/mL is indicative of
Conn syndrome.
Hypokalemia may result in false positive results because of
physiologic aldosterone elevation. Patients with low potassium
levels should undergo repletion before testing (Young, 2007).
Potassium sparing diuretics such as amiloride, and especially
mineralocorticoid receptor blockers such as spironolactone,
alter the RAAS and will affect test results - should be stopped
approximately 6 weeks before testing (Young, 2007).

48. ACE inhibitors – No need to discontinue before testing
Beta blockers - Consider discontinuing for several weeks
before testing
CCB – No need to discontinue before testing

49. ALDOSTERONOMA
Rare (< 1%) causes of an adrenal incidentaloma
 Majority of patients with primary aldosteronism are not
hypokalemic - all patients with hypertension and an
adrenal incidentaloma should be evaluated by
measurements of plasma aldosterone concentration and
plasma renin activity
Patients who are normotensive but have spontaneous
hypokalemia should also be tested for primary
aldosteronism

51. 3. Testing for Adrenal Sex Steroid
Hypersecretion
Rare.
Mc adrenal mass that hypersecretes sex steroid is
an adrenal carcinoma that concomitantly exhibits
cortisol hypersecretion
Routine testing of incidentalomas for sex hormones
is currently not recommended - however, adrenal
androgen testing should be performed for patients
in whom adrenal carcinoma is suspected (Fassnacht
et al., 2016).

52. 4. Testing for Catecholamine Hypersecretion
Pheochromocytoma is found in ~ 3- 5% of patients
with adrenal incidentaloma.
All patients, including those in whom metastatic
disease is suspected, should undergo functional
testing to rule out pheochromocytoma (Adler et al.,
2007; Young, 2007).
Free fractionated plasma metanephrines
24 hour urinary fractionated metanephrine

53. Plasma Free Metanephrines
Patients should not consume food or liquids after
midnight before the study.
Caffeinated beverages - avoided
Acetaminophen - false positive - stopped for at
least 5 days before testing.
Tricyclic antidepressants and phenoxybenzamine
should also be stopped – false positive results
β-blockade - false positive - stop the medication
only on repeat testing

54. Upper limit of normal for the test :
0.61 nmol/L (112 ng/L) for normetanephrine
0.31 nmol/L (61 ng/L) for metanephrine
Elevation beyond :
 2.2 nmol/L (400 ng/L) for normetanephrine
1.2 nmol/L (236 ng/L) for metanephrine
- highly indicative of pheochromocytoma.
 Lesser elevation in plasma free metanephrine levels
necessitates repeat testing
 Serum sample should be drawn with the patient in the
supine position after at least 20 minutes of supine rest.

55. 24-Hour Urinary Fractionated
Metanephrines.
 Patient is instructed to discard the morning's first voided
urine and begin to collect all subsequent voided samples.
 The last sample that is collected is the first morning's
void of the following day.
 Creatinine levels in the collection to verify completeness
of the collection.
 Tricyclic antidepressants and phenoxybenzamine should
be stopped.

56. Ann N Y Acad Sci 1073:332–347, 2006.

59. Approach to the patient with an adrenal
incidentaloma

61. MANAGEMENT - U/L Adrenal masses
Pheochromocytoma and adrenal cancer
• Documented/suspicious - prompt adrenalectomy as
their disease may progress rapidly and untreated
pheochromocytoma may result in significant
cardiovascular complications.
• Alpha-adrenergic blockade should be given before
patients undergo adrenalectomy.
Aldosterone-producing adenomas
• should be offered surgery to cure aldosterone excess

62. Subclinical Cushing's syndrome – Should all patients with this
diagnosis undergo unilateral adrenalectomy?
Younger patients and those who have disorders potentially
attributable to autonomous glucocorticoid secretion (eg,
onset of hypertension, diabetes, obesity, and low bone mass)
and have well-documented glucocorticoid secretory
If adrenalectomy is performed, perioperative glucocorticoid
coverage - administered because of the risk of adrenal
insufficiency, hemodynamic crisis, and death
Patients should be sent home from the hospital on
glucocorticoid replacement and monitored for recovery of the
hypothalamic-pituitary-adrenal axis

63. Lipid-poor adrenal masses – Adrenal masses with either
suspicious imaging phenotype or size larger than 4 cm
should be considered for resection because a substantial
fraction will be adrenocortical carcinomas
Adrenal myelolipomas
◦ followed without surgical excision.
◦ > 6 cm in diameter or when causing local mass-effect
symptoms, surgical removal should be considered.
◦ When adrenal myelolipomas are bilateral, the clinician
should consider the diagnosis of congenital adrenal
hyperplasia

65. B/L macronodular adrenal hyperplasia (BMAH)
• Size is not an indication for surgery, whereas the degree
of cortisol secretory autonomy should guide surgical
decision-making.
• Patients with BMAH and clinical Cushing’s syndrome
usually are best treated with B/L adrenalectomy.
• Patients with BMAH and subclinical Cushing's syndrome
may be managed by resecting the larger adrenal gland.
• Surgical management should be guided by adrenal
venous sampling
MANAGEMENT - B/L Adrenal masses

67. PREOP
. PREPRATION IN PHEOCHROMOCYTOMA
First half of the 20th century - perioperative mortality rates in the
treatment of pheochromocytoma - 26% to 50%.
 Currently, the mortality rate in most specialty centers is
approximately 1%.
Mc- intraoperative hypertension and postoperative hypotension.
Intraoperative hypertension - stimulation of catecholamine release
by anesthetic induction agents as well as by direct manipulation of
the tumor.
Postoperative hypotension - state of hypovolemia created by the
presence of excess circulating catecholamines.
Sudden withdrawal of this stimulus after tumor removal - peripheral
arteriolar vasodilatation - dramatic increase in venous capacitance -
cardiovascular collapse.

68. As soon as the biochemical diagnosis of pheochromocytoma has been
confirmed, α-adrenergic blockade should be initiated to protect
against hemodynamic lability.
Tab Phenoxybenzamine 10 mg twice daily. The dosage can be titrated
upward every 2 to 3 days to a maximum of 40 mg three times daily to
achieve normalization of heart rate and blood pressure. The period of
preoperative conditioning should last at least 2 weeks
This restores sensitivity to vasopressor agents, which can then be used
to treat the patient postoperatively. Phenoxybenzamine is a
nonspecific, noncompetitive (irreversible), long-acting (half-life of
hours) α-adrenergic antagonist.
Side effects of postural hypotension and significant nasal congestion, it
is generally favored over α1 adrenergic selective agents, such as
prazosin and doxazosin.
Nasal congestion - useful indicator of adequate blockade.

69. Calcium channel blockers – if inadequate blood pressure control
after titration of an alpha blocker.
Beta blockers after adequate alpha blockade has been achieved for
the subset of patients with persistent tachycardia, who often have
predominantly epinephrine secreting tumors.
Beta blockers should never be the first agent administered because
a decrease in peripheral vasodilatory beta receptor stimulation
results in unopposed α-adrenergic tone, which may exacerbate
hypertension.
Preoperative volume expansion
oClinical suspicion for hypovolemia should remain high in the
postoperative period, and patients should be resuscitated
aggressively if they become hypotensive or oliguric. Some patients
may require vasopressors after tumor removal, especially if
preoperative alpha blockade is incomplete.

71. ADRENALECTOMY
Adrenalectomy for patients with aldosteronomas,
pheochromocytoma, cortisol-secreting tumors, and
adrenal incidentalomas is safe and effective
May be done laparoscopically, endoscopically via the
posterior approach, or as an open procedure
In patients with known or suspected adrenal carcinoma,
the laparoscopic approach should only be considered if the
adrenal mass is <10 cm and does not appear to be locally
invasive
An open adrenalectomy is recommended for all large (>10
cm) adrenal masses, including those benign imaging
features

73. SURGICAL INDICATIONS FOR ADRENALECTOMY
Functional adrenal mass
Cortisol hypersecretion
Pheochromocytoma
Aldosterone hypersecretion
Mass >4 cm with the exception of myelolipoma
Mass with imaging findings that are suggestive of malignancy
Adrenal incidentaloma that grows more than 1 cm on follow-
up imaging
Extremely large and/or symptomatic myelolipoma
Isolated adrenal metastasis

74. During renal surgery for renal cell carcinoma if:
Adrenal abnormal or not visualized because of large
tumor size onimaging
Vein thrombus to level of adrenal vein
Failed neurosurgical treatment of Cushing disease,
necessitating bilateral adrenalectomy
Selected patients with ectopic ACTH syndrome,
requiring bilateral adrenalectomy
ACTH-independent macronodular adrenal hyperplasia
Primary pigmented nodular adrenocortical disease

75. PRINCIPLES
Minimal manipulation of adrenal mass
Dissection should be in the surrounding tissues
away from adrenal glands ( No touch technique)
Ligation of adrenal arteries
Ligation of adrenal vein be careful at the right side
as vein is short and drain posteriorly directly in IVC
and difficult to control if torn during dissection
called vein of death.

76. Transperitoneal - anterior transabdominal and
thoracoabdominal
Retroperitoneal - flank and posterior lumbodorsal
Transperitoneal laparoscopic lateral adrenalectomy
Laparoscopic retroperitoneal adrenalectomy
Robot assisted Lateral Transperitoneal Adrenalectomy and
Posterior Retroperitoneal Adrenalectomy
Hand assisted Surgery
Laparoendoscopic Single site Adrenalectomy - LESS
Natural Orifice Transluminal Endoscopic Surgery Assisted
LaparoscopicAdrenalectomy - NOTES
APPROACHES

77. Surgical incision over 11th rib for flank
adrenalectomy. The patient is in flexion, with the
kidney rest deployed to maximally expose the right
retroperitoneum.
Posterior approach - possible locations for
lumbodorsal incisions.

78. Positioning for thoracoabdominal surgery. A
body roll elevates the flank on the side of
surgery, and the arm and shoulder are rotated
away, supported by a sling.
Transperitoneal approach may be attempted
through a midline incision or subcostal
incision. The subcostal incision can be
extended into a full chevron for bilateral
adrenalectomy or if a large unilateral tumor is
encountered.

80. Anterior Transabdominal Approach
Indications-
large or potentially malignant tumors for which adequate
exposure for extensive dissection is needed.
In cases of inferior vena caval or extensive nodal involvement
• Subcostal or chevron incision - better exposure of the superior
and lateral aspects of the adrenal gland
• Midline approach - extra adrenal pheochromocytoma is
suspected along the great vessels or in the pelvis.

81. ◦ Positioning - Supine with a body roll placed
under the back at the level of the costal margin
to accentuate the costal margin
◦ Incision - Two fingerbreadths below the costal
margin and extends medially to the midline.
◦ External oblique, internal oblique, and
abdominal muscles are divided laterally, and the
rectus muscle and sheath are divided medially.
◦ The peritoneum is entered with sharp
and the falciform ligament is ligated.

82. Through gastrocolic ligament / lienorenal ligament /
transverse mesocolon / lesser omentum
Left Adrenalectomy

83. Right Adrenalectomy
After the peritoneum is entered, the hepatic flexure is
mobilized inferiorly and the liver is retracted superiorly.
Kocher maneuver is performed to mobilize duodenum (2nd
part) and inferior vena cava is exposed

86. Monitoring when surgery not performed
 Incidentaloma with a benign appearance on imaging
- repeat imaging after 12 months
Resecting any tumor that enlarges by more than 1 cm
in diameter during the follow-up period is considered
Surgical removal should be considered for masses ≥4
cm to avoid missing adrenal carcinomas, particularly in
younger patients.
repeating the baseline DHEAS and the overnight DST
annually for four years in cases where initial evaluation
is negative
NO CLEAR GUIDELINES

87. SUMMARY & RECOMMENDATIONS
All patients with adrenal incidentalomas should be evaluated
for the possibility of malignancy and subclinical hormonal
hyperfunction:
A homogeneous adrenal mass <4 cm in diameter, with a
smooth border, and an attenuation value <10 HU on
unenhanced CT, and rapid contrast medium washout (eg, >50
% at 10 minutes) is very likely to be a benign cortical
adenoma.
Irregular shape, inhomogeneous density, high unenhanced CT
attenuation values (>20 HU), delayed contrast medium
washout (eg, <50 % at 10 minutes), diameter >4 cm, and
tumor calcification – adrenal carcinoma or metastasis

88. Pheochromocytoma should be excluded in all patients
with adrenal incidentalomas with unenhanced CT
attenuation >10 HU by measuring 24-hour urinary
fractionated metanephrines and catecholamines or
plasma fractionated metanephrines.
Subclinical Cushing's syndrome should be ruled out by
measuring baseline dehydroepiandrosterone sulfate
(DHEAS) and performing the 1 mg overnight DST
If the adrenal incidentaloma patient is hypertensive or is
hypokalemic, a plasma aldosterone and plasma renin
activity should be obtained to screen for primary
aldosteronism

89. Surgery is recommended for all patients with biochemical
documentation of pheochromocytoma
Surgical resection for patients with subclinical Cushing's
syndrome who are good surgical candidates and who have
disorders potentially attributable to excess glucocorticoid
secretion (eg, recent onset of hypertension, diabetes, obesity,
and low bone mass) is suggested
In a patient with a known primary malignancy elsewhere who
has a newly discovered adrenal mass that has an imaging
phenotype consistent with metastatic disease, performing a
diagnostic CT-guided fine-needle aspiration (FNA) biopsy may
be indicated, but only after excluding pheochromocytoma with
biochemical testing.
Adrenal biopsy is not needed if the patient is already known to
have widespread metastatic disease.

90. excision is recommended if the initial imaging phenotype is
suspicious
All adrenal masses larger than 10 cm, including those masses with
benign imaging phenotypes, we suggest an open adrenalectomy
rather than a laparoscopic procedure
Adrenal masses > 4 cm in diameter - surgical resection. However,
the clinical scenario, imaging characteristics, and patient age
frequently guide the management decisions in patients with <4 cm
diameter.
If benign appearance on imaging, repeat imaging study at 12
months is suggested
Removal of any tumor that enlarges by more than 1 cm in
diameter during the follow-up period
Baseline DHEAS and an overnight DST be repeated annually for
four years in cases where initial evaluation is negative.

91. REFERENCES