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

4. SURGICAL ANATOMY

8. RELEVANT PHYSIOLOGY

11. 3 metabolites
Metanephrine
Nor metanephrine
VMA
2 enzymes
COMT
MOA

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

14. 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.

15. 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

16. PLASMA OR
URINARY
METANEPHRINES

19. 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

20.  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

24.  Other imaging studies:
I123 MIBG Scintigraphy
FDG PET
6-FDOPA PET
Somatostatin receptor based scans

25. FUNCTIONAL ADRENAL TUMORS
CUSHING SYNDROME HYPERCORTISOLISM
CONNS SYNDROME PRIMARY ALDOSTERONISM
PHEOCHROMOCYTOMA TUMOR OF ADRENAL MEDULLA
ADRENAOCORTICAL CARCINOMA HIGHLY AGGRESSIVE TUMOR

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
 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.

28. PRIMARY HYPERALDOSTERONISM
 Symptoms: Nocturia, polyuria, muscle cramps,
palpitations
 Signs: Hypertension, hypernatremia, hypokalemia

29. 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

30. 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.

31. PHEOCHROMOCYTOMA
 Catecholamines: epinephrine,
norepinephrine, dopamine
 Metanephrines: metanephrine,
normetanephrine

32. PHEOCHROMOCYTOMA
 Recommendation
 24 hr urine fractionated catecholamines
and 24 hr urine fractionated
metanephrines.
 Plasma free metanephrines

33. ADRENOCORTICAL CARCINOMA
 Symptoms/Signs:
 “Salt” – Aldosteronsim
 “Sugar” – Cushing’s syndrome
 “Sex”
○ androgens: hirsutism, acne, oily skin,
amenorrhea, oligomenorrhea, increased
libido
○ estrogens: gynecomastia, testicular
atrophy

34. 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 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

38. 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.

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.

45. THANK YOU