The document provides an overview of adrenal tumors, including their classification into adrenal cortical and medullary tumors, and discusses benign and malignant forms. It details the clinical manifestations, diagnostic studies, and treatment options including surgical resection and medical management for hormone-producing tumors. The document also addresses the management of adrenal malignancies such as adrenocortical carcinoma, including diagnostic approaches and the importance of follow-up care post-surgery.

1. ADRENAL TUMOR
PRESENTED BY
SWATILEKHA DAS
ASST. PROFESSOR

2. ADRENAL GLANDS
The adrenal (or suprare
nal) glands are paired
endocrine glands situat
ed over the medial
aspect of the upper
poles of each kidney.
They secrete steroid and
catecholamine
hormones directly into
the blood.

4. CLASSIFICATION OF
ADRENAL TUMOR
1. Adrenal cortical
tumors
a. Benign(Adenoma)
b. Malignant(Adrenoc
ortical carcinoma)
2. Adrenal medullary
tumors
a. Benign(Ganglineuroma)
b. Malignant(Neuroblasto
ma)
Other tumors are-
Myelolipoma
Adrenal Mets

5. Adrenal Cortical Adenoma
• Most common neoplasms arising from the adrenal gland.
• The incidence of adenomas rises with age
• May be unilateral or bilateral.

6. Clinical Manifestations
• Small size,non hormone producing are usually
asymptomatic, incidently diagnosed in CT/MRI done for
some other.
• Large size, non functioning tumors frequently present
with abdominal discomfort or back pain. With increasing
use of abdominal imaging they are detected early now.
• Hormone producing adenomas will produce signs &
symptoms of the hormones produced that is :
a. Cushing syndrome if increased level of Cortisol
b. Conn’s syndrome if increased of Aldosteron

7. Cushing syndrome
• Weight gain / central obesity
• Diabetes
• Hypertension
• Depression
• Osteoporosis
• Skin changes (strial, facial plethora, ecchymosis, acne)
• Hypokalemia

8. Conn’s syndrome
• Headache
• Muscle weakness
• Hypertension
• Cramps
• Polyuria
• Nocturia
• Intermittent paralysis
• Polydipsia

9. Diagnostic studies
• Complete history & clinical examination
• Biochemical evaluation
 Morning & midnight plasma cortisol measurement
 Dexamethasone suppression test
 24 hr urinary cortisol measurement
 Serum potassium, plasma aldosterone & plasma renin
activity
• Abdominal imaging
 CT scan
 MRI scan
• Adrenal vein catheterization

10. Treatment
• Surgical Resection (nonfunctioning tumor > 4 cm & small
tumors that increases in size over time should undergo
surgical resection)
• Non-functioning tumors smaller than 4 cm should be
followed up after 6, 12, 24 months by imaging &
hormonal evaluation.
• Medical treatment for functioning tumor-
 Dietary management
 Spironolactone – Conn’s Syndrome
 Ketoconazole – Reduce steroid synthesis- Cushing
syndrome
• Surgical management
 Unilateral Adenoma- Unilateral Adrenalectomy
 Bilateral Adenoma- Bilateral Adrenalectomy

11. Pre-op management
• Conn’s & cushing syndrome related disease (HTN, DM)
should be treated & biochemical abnormalities should be
corrected.
• Patients with cushing syndrome are at an increased risk
of Hospital Acquired Infection & thromboembolic &
myocardial complications
• Therefore prophylactic anticoagulation & the use of
prophylactic antibiotics are essential.

12. Post- op management
• Supplementary cortisol should be given after surgery. In
total 15 mg is required parentally for the first 12hrs
followed by a daily dose of 100mg for 3 days which is
gradually reduced thereafter.
• After unilateral adrenalectomy the contralateral
suppressed gland need upto 1 year to recover adequate
function.

13. Adrenocortical Carcinoma
• A rare malignancy with an incidence of 0.5 to2 per million
but gradually poor prognosis.
• Peaks in children in the first decade of life and adults in
the fourth to fifth decades of life.
• Slight female predominance.
• The majority of adrenocortical carcinomas are unilateral/

14. Clinical Features
• Approx. 60% present with evidence of steroid hormones
excess i.e. Cushing syndrome. Else any hormone
excess can be the presentation.
• Patients with non-functioning tumors frequently complain
of abdominal discomfort or back pain caused by large
tumors.

15. Diagnostic Studies
• History taking & physical examination
• Biochemical evaluation –
 Morning & midnight plasma cortisol measurement
 Dexamethasone suppression test
 24 hr urinary cortisol measurement
 Serum potassium, plasma aldosterone & plasma renin activity
• Abdominal imaging-
 CT scan
 MRI scan
 MRI angiography
 As distant metastasis is frequently present so a CT scan of
the lung is recommended.

16. Treatment
• Complete tumor resection is associated with favourable
outcome.
• Laparoscopic adrenalectomy is associated with a high
incidence of local recurrence & can’t be recommended.
• Adjuvent chemotherapy- patients should be treated with
alone or in combination with Etoposide, Doxorubisin or
Cisplatin in 30% & 50% of cases respectively.
• Adjuvent Rdiotherapy- May reduce the rate of local
recurrence.
• Follow up- After surgery, restaging every 3 months is
required as the risk of tumor relapse is high.

17. Staging of Adrenal Carcinoma
The WHO clasification of 2004 is based on the Mcfarlane
Classification & defines four stages:
I stage – Tumor < 5 cm
II stage – Tumor >5 cm
III stage – Locally invasive tumors
IV Stage – Tumor with distant metastasis

18. Surgery of the Adrenal Gland
• Laparoscopic or Retroperitoneoscopic Adrenalectomy
had become the gold standard in the resection of
Adrenal tumors, except for tumors with signs of
malignancy.
• An open approach should be considered if radiological
signs, distant metastases large tumors (>8-10 cm) or a
distant hormonal pattern suggest malignancy.
the surgical access in such cases should be
Thoracoabdominal.