incidentally discover adrenal mass approach and management

1. Adrenal incidentaloma and its
management

2. • A clinically unapparent mass detected
incidentally by imaging studies conducted
for other reasons.
• There existence as a clinical entity is a
byproduct of advanced medical imaging.

3. epidemiology
• Incidentaloma- 8% of autopsies
-1-4% of abdominal imaging studies.
• Incidental adrenal mass increases with age with less than
.5% risk below 25 year of age and up to 7% in more than
75 year of age.
• 20% of incidentaloma -potential surgical lesions

4. Classification
IN PATIENT WITH HISTORY Of IN PATIENT WITHOUT HISTORY
MALIGNANT DISEASE MALIGNANT DISEASE
metastatic disease(2%)
Non funcionig adenomas(75%)
pheochromocytoma(4%)
cortisol producing adenoma(7%)
adrenocortical carcinoma(4%)
adrenal cyst(2%)
ganglioneuroma
myeolipoma(2%)
conns adenoma(1%)

5. • In patient with a history of malignant disease, metastatic disease is the most
likely cause of adrenal mass, particularly when they are bilateral .
• In 80% case incidentaloma- nonfunctioning cortical lesions.
• Adrenal metastases are likely in patients with a history of cancer elsewhere
• Metastsis are generally from- renal cell carcinoma, melanoma, lung cancer,
colon cancer, and lymphoma.

6. INCIDENTALOMA
Is it malignant
Is it Is functioning
Is there any indication for surgical intervention

7. Clinical evaluation
• Detail history
• Biochemical investigation
• Hormonal evaluation
• Imaging

8. History
Hypertension, obesity, glucose intolerance -Cushing syndrome
Headache ,palpitation ,perfuse sweating-pheochromocytoma
Significant hypertension with hypokalemia-aldosterone producing
adenoma
History of malignancy –metastasis
History of familial condition-pheochromocytoma

9. Biochemical investigation
• Serum electrolyte level
• Plasma glucose level
• Lipid profile
• Complete blood count
• Plasma metanephrine (more convinient, high false positive rate, more
sensitive, less specific)
• 24 hour urinary metanephrine(more specific)

10. Hormonal evaluation
• 10% of adrenal incidentalomas -metabolically active.
• All adrenal incidentalomas demand a metabolic evaluation whether symptomatic or
not.
• Annual follow-up for 3 to 4 years is recommended for metabolically silent masses

11. Hormonal Evaluation
• Morning And Midnight Plasma Cortisol Measurements;
• A 1-mg Overnight Dexamethasone Suppression Test;
• 24-hour Urinary Cortisol Excretion(2 times)
• Salivary cortisol(2 times)(convenient now days, OPD basis)
• serum cortisol(adrenal insufficiency)
• ACTH level
• 24-hour Urinary Excretion Of Catecholamines, Metanephrines Or;
• Plasma Aldosterone And Plasma Renin Activity;
• Serum DHEAS, Testosterone Or 17β-hydroxy Estradiol (Virilizing Or
Feminizing Tumor).

12. Contd…
• High dose dexamethasone suppression test
• 24 hour free urinary aldosterone level

13. IMAGING
• Ultrasound –not much helpful as adrenal so far from
body surface
• left adrenal gland -not visualized by ultrasound.
• CECT performed in all patient with adrenal mass.
• CECT underestimate the tumour size by approx. by
20%
• Size, laterality, homogenecity, vascularity, density and
anatomic relationship can be accurately assessed

14. UNENHANCED AND ENHANCED CT
• Adenomas being lipid rich, an adrenal lesion measuring less than 10
HU an adenoma 100% of cases regardless of the size.
• Lipid poor adenomas can measure between 10 and 20 HU, in these
cases contrast scans are used and enhancement is measured at 60 s
and 15 min. Absolute washout of contrast at 15 min (> 95% ) is lipid
poor adenoma .
• Masses >6 cm should be considered malignant until proved otherwise.

15. • Character suggestive of benign lesion on ct-
• Well defined border
• High lipid content
• Low vascularity
• Rapid washout of contrast

16. Character in CT suggesting of malignancy
•Ill defined border
•Necrosis
•Internal calcification

17. MRI
• Based on Chemical shift
• The lipid content of adenoma causes signal dropout on MRI.
• 30% of adrenal adenomas do not showing signal dropout on MRI.
• MRI is largely diagnostically equivalent to non-contrast CT as both
are equally capable in quantifying intracellular lipid.
• MRI angiography is useful to exclude tumor thrombus in the vena
cava, which must be excluded before adrenalectomy
• More expensive and not superior on contrast CT

19. FDG PET
• Highly sensitive and specific to distinguish between
benign and malignant lesion
• Can't distinguish between adrenocortical carcinoma
and metastasis

20. Metaiodobenzylguanidine (MIBG) scan
• MIBG is an analogue of noradrenaline and it
selective uptake by chromaffin cells in the
adrenal (phaeochromocytoma) or extra-adrenal
locations.
• MIBG may be helpful in diagnosing and
localising recurrent,metastatic,multifocal
phaeochromocytoma in difficult locations.

21. Adrenal venous sampling
• Done in patienty
• With-unilateral mass suspicious of
aldosteronoma and contralateral side cant
be ruled out
• Age >40 year
• Aldosterone/cortisol ratio observed
• Laterization confirm aldosteronoma

22. FNAC
• Only in patient with history of extra adrenal malignant disease to confirm metastasis
• rule out pheochromocytoma

23. Role of Adrenal biopsy
THE ROLE FOR ADRENAL BIOPSY HAS BEEN LIMITED FOR THE FOLLOWING
REASONS:
• Modern imaging affords super diagnostic capabilities.
• Histologically adenomas cannot be reliably differentiated from adrenal carcinomas.
• Adrenal biopsy is not without risk.
• Never biopsy an adrenal mass until pheochromocytoma has been
biochemically excluded
• The indication for adrenal gland biopsy-- adrenal gland metastasis.

24. PHEOCHROMOCYTOMA

25. ALDOSTERONOMA

26. CUSHING SYNDROME

27. Management of adrenal incidentaloma
• Non-functioning tumors smaller than 4cm -
followed-up after 6, 12 and 24 months and
then annually by imaging.

28. Surgical Indications for
Adrenalectomy
• Functional adrenal mass ( Cortisol hypersecretion,
Pheochromocytoma, Aldosterone hypersecretion)
• Mass > 4 cm with exception of myelolipoma
• Mass with imaging findings that are suggestive of
malignancy (lipid-poor, heterogeneous, irregular
borders, infiltrates surrounding structures, )

29. Surgical indication contd.
• Adrenal incidentaloma that grow greater than 1 cm on
follow-up imaging.
• Extremely large and/or symptomatic myelolipoma.
• isolated adrenal metastasis
• ACTH-independent macronodular adrenal
hyperplasia(primary adrenal cushing syndrome)
• Incidentaoma(3-4cm)-patients preference,if patient
wish to avoid the burden of surveillance

30. Surgical indication contd.
• DURING RADICAL NEPHRECTOMY FOR RENAL CELL CARCINOMA IF:
✓ Adrenal abnormal or not visualized due to large renal tumor size on imaging.
✓ Large (≥7 cm) upper pole mass.
✓ Vein thrombus to level of adrenal vein

31. aldosteronoma
• Unilateral laparoscopic adrenalectomy is an effective therapy in patients with clear
evidence of unilateral or asymmetrical bilateral disease.
• A subtotal resection is favoured in the case of a typical Conn’s adenoma

32. Cortisol producing adenoma(cushings
adenoma
➢ A unilateral adenoma is treated by adrenalectomy.
➢ In cases of bilateral ACTH-independent disease , bilateral
adrenalectomy is the primary treatment.
➢ ectopic ACTH-dependent Cushing’s syndrome ,an irresectable
or unlocalised primary tumour and failure of TSPS should be
considered for bilateral adrenalectomy as this controls
hormone excess.
➢ Subclinical(no sign and symptoms) Cushing’s syndrome caused
by unilateral adenoma is treated by unilateral adrenalectomy.

33. Adenocortical carcinoma
• ACC represent- 2% of adrenal tumour measuring 4cm or smaller
• 6% of adrenal tumour measuring >4cm
• Complete tumour resection (R0) is associated with favourable survival and should be
attempted whenever possible.
• In order to prevent tumour spillage and implantation metastases, the capsule must
not be damaged.
• En bloc resection preferred if invading organs
• Laparoscopic adrenalectomy is associated with a high incidence of local recurrence
and NOT recommended.
• Tumour debulking plays a role in functioning tumours to control hormone
excess.
• Chemotheapy-adjuvant setting,unresectble tumour,metastatic tumour
• Chemo agent-mitotone,cisplatin,doxorubicin,,etoposide

34. • Adjuvant radiotherapy -reduce the rate of local recurrence.
• restaging every 3 months
• Prognosis depends on the stage of disease(mcferlane
classification) and complete removal of the tumour.
• Patients with stage I or II disease have a 5-year survival rate
of 25% whereas patients with stage III and stage IV disease
have 5-year survival rates of 6% and 0% respectively.

35. Pheochromocytoma
• Laparoscopic resection is now routine in the
treatment of phaeochromocytoma.
• tumour larger than 8–10cm ,radiological signs of
malignancy-open

38. Surgical approach
Laparoscopic
Open
Robotic
Surgical
approach

39. Laparoscopic Approach
• Laparoscopic adrenalectomy -current standard of care for
adrenal lesions.
• Laparoscopic adrenalectomy either done Transabdominal
Approach or posterior Retroperitonescopic Approach.
• Tumour <6cm,bilateral tumour,prior abdominal surgery-
retroperitoniscopic approach
• Obese mae (bmi>32)-transabdominal approach

40. Retroperitonioscopic approach

41. Transabdominal approach

42. OPEN SURGERY
Indications for Open Surgery
• Adrenal cortical carcinoma.
• the extension of adrenal vein tumor thrombus into the
inferior vena cava
• Tumour > 8 cm(some consider >5-6 cm).
• Malignant pheochromocytoma
• Clinical feminization present(almost all feminizing tumors are
malignant)

43. Open surgery contd.
• Adrenal glands are located deep in upper abdominal cavity.
• Glands are equidistant from all ipsilateral body surfaces, necessitating large open incisions
regardless of point of entry.
• Open adrenalectomy can be performed through either a transperitoneal or retroperitoneal
approach.
1. The transperitoneal approaches include midline, subcostal, and thoracoabdominal.
2. The retroperitoneal approaches include flank and posterior lumbodorsal.
• The advantages of the transperitoneal approaches are better exposure for larger tumors and
excellent access to the great vessels and retroperitoneum. The main disadvantages are
prolonged ileus and difficult exposure in morbidly obese patients.

47. THORACO ABDOMINAL APPROACH

48. ROBOTIC SURGERY
• The advantages of robotics should be the superior three-dimension visualization
and hand-like ability of the robotic arms to perform the microdissection of the plane
between the adrenal and the great vessels.
• The robotic approach has the disadvantage of increased expense and limited
availability compared to standard laparoscopy.

49. SURGICAL PRINCIPALS
• Minimal manipulation of adrenal mass.
• Dissection should in the surrounding tissues away
from adrenal glands ( N0 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.

50. THANK YOU