Adrenal Tumors



Adrenal Tumors


Ronald Merrell



Ms. Lucas is a 78-year-old African American woman. She is a retired university professor who had an episode of ureterolithiasis several months ago for the first time in her life. She was evaluated for residual stones and renal pathology by computed tomography (CT) scan and a 5-cm left adrenal mass was identified. Ms. Lucas has been hypertensive for many years and is well controlled with an angiotensin-receptor antagonist. She is referred to you for consideration of the adrenal mass.



What is the significance of an asymptomatic adrenal mass?

View Answer

The generous application of CT discloses a great deal of unsuspected and usually innocuous masses. Adrenal masses are identified in 0.06% of the general population; although most are of no significance, the chance finding of a silent but significant adrenal tumor must be seized by evaluation.



What is the differential diagnosis of an incidental adrenal mass discovered by CT scan?

View Answer

The adrenal gland is a common site for metastatic disease, and this diagnosis should be strongly entertained in patients with bilateral masses or a history of cancer. Primary tumors of the adrenal cortex include adenomas, carcinomas, and myelolipomas. They may be functional with excess hormonal status or without function. The adrenal medulla may develop neuroblastoma, neuroganglioma, or (in adults) pheochromocytoma. Pheochromocytoma may be malignant or benign.



How is an incidental adrenal mass evaluated?

View Answer

The first test is to rule out pheochromocytoma even if the patient has no clinical manifestations of catecholamine excess. Testing also should include cortical hormone testing for cortisol. If the tumor has no endocrine activity and there is a suspicion of metastatic disease, a CT-guided needle biopsy may clarify the situation.



How is an incidental adrenal tumor treated?

View Answer

If the tumor has no endocrine activity and is less than 3 cm in diameter, the patient may be followed with repeat CT at 6 months and again at 1 year. If endocrine activity is discovered, resection is indicated. Tumors smaller than 3 cm are quite unlikely to represent malignant disease, and expectant management is safe. For tumors larger than 5 cm, resection is the treatment of choice, regardless of secretory status. The probability of malignancy climbs into the clearly finite range of some 10%, and expectant management is not reasonable. If the tumor is between 3 and 5 cm, there is not a clear answer as to the best management, and the next steps must be considered in light of the patient’s informed consent and overall health management.



What are the anatomic and functional characteristics of the adrenal glands?

View Answer

The adrenal glands lie above the kidney on either side and represent a composite of mesodermal cortex that envelops the medulla, which derives from the neural crest sympathogonia. The cortex has three layers:



  • The most superficial layer is the zona glomerulosa, which synthesizes the steroid mineralocorticoid hormone aldosterone upon stimulation by angiotensin II. This synthesis is possible because of the phenotypic expression of 18-hydrozylase.


  • Below the zona glomerulosa, the zona fasciculate synthesizes glucocorticoids.


  • The inner layer synthesizes the androgen dehydroepiandrosterone (DHEA).

The zona fasciculata and reticulata are controlled by adrenocorticotrophic hormone (ACTH) in the pituitary-adrenal axis.



What supplies blood to the adrenal glands?

View Answer

The superior adrenal artery is a branch of the inferior phrenic artery; the middle adrenal artery arises directly from the aorta; and the inferior adrenal artery branches from the renal artery. Venous drainage on the right is directly into the vena cava, and this vein can be treacherously short. Venous drainage on the left is into the renal vein.

Ms. Lucas tells you she has no endocrine symptoms and her blood pressure has been stable for many years. She only switched to the angiotensin receptor antagonist in order to avoid diuretics. However, she had a left mastectomy and axillary node dissection 20 years ago for infiltrating ductal carcinoma. She has been followed diligently and has consistently had a reassuring report with regard to physical examination and chest radiograph. Your testing begins with urinary catecholamine and metanephrine determination, which is normal. Her urinary cortisol levels are also normal.



What is the next step in her management?

View Answer

Even though the history of breast cancer is distant, CT-guided needle biopsy of the adrenal gland is appropriate. Needle biopsy is not particularly useful to distinguish benign from malignant adrenal tumors, and needle biopsy of a pheochromocytoma is dangerous in that a catastrophic release of catecholamine may occur. Needle biopsy should probably be reserved for cases of possible metastatic disease.

Ms. Lucas has a needle biopsy after CT-guided needle biopsy to rule out pheochromocytoma and adrenal cortical cells are recovered.



What is the treatment for an adrenal cortical tumor 5 cm or larger that has no endocrine function?

View Answer

Adrenalectomy is strongly recommended if this is consistent with overall patient management. A tumor of 5 cm may be resected by laparoscopy or laparotomy or through a retroperitoneal approach. Laparoscopy becomes problematic when the gland is large and when the tumor is malignant with uncertain invasion of surrounding tissue. The recommendation of laparotomy to explore has lost impetus, and advanced imaging techniques such as spiral CT, even with tumors that have a strong likelihood of bilaterally such as pheochromocytoma, have come into favor. The posterior approach offers no advantage over laparoscopy, which may become the preferred operation for all small adrenal tumors.

At operation, a benign adrenal adenoma is removed by laparoscopy.



What further treatment is needed?

View Answer

Follow the laparoscopy with physical examination and CT every 2 years. The histology of adrenal cortical tumors is not sufficiently precise to absolutely differentiate between cortical adenomas and carcinoma. Occasionally, only malignant behavior such as local or distant metastasis declares a tumor to be a cancer.

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Sep 23, 2016 | Posted by in UROLOGY | Comments Off on Adrenal Tumors

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