Adrenaloma

adrenal incidentaloma

1. Adrenal Incidentaloma Dr.Jaya Sakthi Post-Graduate 2nd year Department of General Surgery 06/04/2019

2. OUTLINE Surgical anatomy Relevant physiology Incidentaloma definition and classification Evaluation Functioning tumors Management Surgical indications Surgical options

3. SURGICAL ANATOMY

4. Relevant physiology

5. 3 metabolites Metanephrine Nor metanephrine VMA 2 enzymes COMT MOA

6. Adrenal Incidentaloma Incidentally discovered adrenal masses, also termed clinically inapparent adrenal masses or incidentalomas, are discovered through imaging performed for unrelated nonadrenal disease. Found in 4-6% on CT scans Functioning or nonfunctioning

7. EVALUATION Evaluation begins with history taking, with a focus on prior malignant disease, hypertension, and symptoms of glucocorticoid or sex steroid excess. Laboratory investigations to evaluate abnormalities in physiological functions. Imaging studies.

8. Laboratory investigations To evaluate abnormalities in HPA Axis: Baseline morning plasma cortisol 24 hrs urinary free cortisol Midnight salivary or free cortisol Morning plasma cortisol after overnight 1mg dexamethasone suppression Others: Serum testosterone DHEA Sulphate Androstenodione 11 deoxycortisol

9. PLASMA OR URINARY METANEPHRINES

10. IMAGING Characteristics suggestive of a benign lesion on CT scan include homogeneous appearance, well-defined borders, high lipid content, rapid washout of contrast material, and low degree of vascularity. Features that are concerning for malignancy include irregular or ill-defined borders, necrosis, internal calcifications or hemorrhage, and high vascularity

11. Adrenocortical adenoma: * <4cm * Lipid rich(<10 HU) * homogenous with smooth borders * 30% Lipid poor  10-30 HU  Contrast washout >60% in 15 minutes Malignancy: * Heterogenous lesions with irregular margins * Calcifications Suspicion of malignancy: <2% for lesions < 4cm 2%-6% for lesions 4-6cm 25% for lesions >6cm

12. Other imaging studies: I 123 MIBG Scintigraphy FDG PET 6-FDOPA PET Somatostatin receptor based scans

13. FUNCTIONAL ADRENAL TUMORS CUSHING SYNDROME HYPER CORTISOLISM CONNS SYNDROME PRIMARY ALDOSTERONISM PHEOCHROMOCYTOMA TUMOR OF ADRENAL MEDULLA ADRENAOCORTICAL CARCINOMA HIGHLY AGGRESSIVE TUMOR

14. Cushing’s Syndrome Symptoms : weight gain, central obesity, rounded facies , dorsocervical (back of the neck) fat pad, easy bruising, thin skin, poor wound healing, purple abdominal striae , acne, hirsutism , infertility, depression, irritability, opportunistic infections Signs : hypertension, diabetes, impaired glucose tolerance, osteoporosis, osteopenia, hypokalemia, leukocytosis with relative lymphopenia ,

15. Cushing’s Syndrome Screening tests *24 hour urine cortisol Values higher than 3-4 times normal are highly suggestive of autonomous cortisol secretion. *Overnight 1-mg dexamethasone suppression test Patient takes 1 mg dex pill at 11 PM, then fasts, then presents to lab at 8:00 AM for measurement of serum cortisol . Serum cortisol level > 5 mcg/dl is highly suggestive of autonomous cortisol secretion.

16. Primary hyperaldosteronism Symptoms : Nocturia, polyuria, muscle cramps, palpitations Signs : Hypertension, hypernatremia, hypokalemia

17. Primary Aldosteronism Plasma renin activity (PRA) and plasma aldosterone concentration Aldo/PRA ratio of  20 with aldo level of  15 ng /dl is positive result

18. Pheochromocytoma Symptoms : (in paroxysms) tachycardia, palpitations, pallor, tremor, headache, diaphoresis. May be precipitated by maneuvers that increase intra-abdominal pressure (Valsalva, lifting, pregnancy, postural), or by anxiety, or by medicines such as reglan. Signs : Hypertension, orthostatic hypotension, pallor, retinopathy, fever, tremor ,tachycardia, diaphoresis, headache, cardiac arrhythmias, left ventricular dysfunction.

19. Pheochromocytoma Catecholamines : epinephrine, norepinephrine , dopamine Metanephrines : metanephrine , normetanephrine

20. Pheochromocytoma Recommendation 24 hr urine fractionated catecholamines and 24 hr urine fractionated metanephrines . Plasma free metanephrines

21. Adrenocortical Carcinoma Symptoms/Signs : “Salt” – Aldosteronsim “Sugar” – Cushing’s syndrome “Sex” androgens : hirsutism , acne, oily skin, amenorrhea, oligomenorrhea , increased libido estrogens : gynecomastia , testicular atrophy

22. MANAGEMENT Surgery is the treatment of choice for endocrine active or likely malignant and resectable ACTs and for all PCs and PGLs. A course of cortisol-lowering agents such as ketoconazole or metyrapone may be considered before surgery. A course of cortisol-lowering agents such as ketoconazole or metyrapone may be considered before surgery.

23. The preoperative management of PC and PGL resection includes α-blockade and volume repletion. Finally, the risk of hemodynamic instability after surgical removal of PC or PGL requires close monitoring in the postoperative period in an intensive care unit

24. ADRERNALECTOMY Open adrenalectomy can be broadly classified into transperitoneal and retroperitoneal approaches. Transperitoneal approaches include the anterior transabdominal and thoracoabdominal approaches, where the main advantages lie in excellent surgical exposure and better access to the hilum and great vessels. Disadvantage: intra abdominal organ injury.

25. Retroperitoneal approaches include the flank and posterior lumbodorsal approaches, which result in a smaller operative field but are associated with less ileus and shorter hospitalization. In addition, the retroperitoneal approach is ideal for the morbidly obese patient.

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