12. 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
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.
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
20. Adrenocortical adenoma:
*Lipid rich(<10 HU)
*homogenous with smooth borders
*30% Lipid poor 10-30 HU Contrast
washout >60% in 15 minutes
*Heterogenous lesions with irregular margins
Suspicion of malignancy:
<2% for lesions < 4cm
2%-6% for lesions 4-6cm
25% for lesions >6cm
24. Other imaging studies:
I123 MIBG Scintigraphy
Somatostatin receptor based scans
26. 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 ,
27. CUSHING’S SYNDROME
*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.
29. PRIMARY ALDOSTERONISM
Plasma renin activity (PRA) and plasma
Aldo/PRA ratio of 20 with aldo level of
15 ng/dl is positive result
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
Signs: Hypertension, orthostatic hypotension, pallor,
retinopathy, fever, tremor ,tachycardia, diaphoresis,
headache, cardiac arrhythmias, left ventricular
Surgery is the treatment of choice
for endocrine active or likely malignant
and resectable ACTs and for all PCs
A course of cortisol-lowering agents such
as ketoconazole or metyrapone may be
considered before surgery.
A courseof cortisol-lowering agents
such as ketoconazole or metyrapone
may be considered before surgery.
35. 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 postoperativeperiod
in an intensive care unit
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
Disadvantage: intra abdominal organ injury.
41. 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.