Adrenal Glands Incidental Om A

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Adrenal Incidentaloma

By Wichien Sirithanaphol


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Adrenal Glands

Paired, mustard-

colored structures Retroperitoneal space

Superior and slightly medial to the kidneys

Level of the 11th ribs

Measures 5 x 3 x 1 cm and weighs 4 to 5 g

Blood flow of 2000 mL/kg/min


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Embryology

Outer : cortex Inner : medulla

Adrenal cortex

- Mesodermal tissue near the gonads on the adrenogenital ridge

- Ectopic adrenocortical tissue : ovaries, spermatic cord and testes

Adrenal medulla

- Ectodermal in origin

- Arises from the neural crest

-Migrate to the para-aortic and paravertebral areas andtoward medial aspect of adrenal cortex to form the medulla

- May also be found in neck, urinary bladder, and para-aortic


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Neural creast

adrenal medulla

ganglia of the sympathetic trunk

sympathetic plexus

adrenal cortex

undifferentiated gonad


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The Adrenal Incidentaloma

Incidentally discovered adrenal masses Discovered through imaging

CT and MRI

Unrelated/nonadrenal disease

First described in the early 1980s

1

4 % of abdominal imaging studies > 60 years: greater than 4 %


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Differential diagnosis


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Diagnosis

Signs and symptoms : hypersecreting hormone

Conn syndrome

Cushing syndrome

Pheocgromocytoma

If no signs and symptoms

Non-functionig VS Functioning tumor

Benign VS malignant

Need Biochemical studies or imaging studies?

Follow up VS adrenalectomy

Open VS laparoscopic adrenalectomy


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Diagnostic hormonal test

Low dose (1mg) dexamethasone test 24-hour urine cortisol level

24-hour urine

Catecholamines

Metanephrines

Vanillylmandelic acid

Plasma metanephrine

Serum electrolytes

Plasma aldosterone

Plasma renin

Subclinical Cushing's syndrome

Pheochromocytoma

Aldosteronoma


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Imaging studies

CT scan

Homogenous and well-encapsulated

Smooth and regular margins

Hypoattenuating lesions (< 10 Hounsfield units)

Hyperattenuating (> 18 Hounsfield units)

Inhomogeneous

Irregular borders

Evidence of local invasion

Adjacent lymphadenopathy

Adrenal adenoma

Adrenal cancer


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Aldosteronoma


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Aldosteronoma


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Left adrenocortical cancer


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Left-sided pheochromocytoma


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Right-sided pheochromocytoma


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Imaging studies

MRI(T2-weighted imaging)

Low signal intensity when compared to the liver

Adrenal mass : liver ratio less than 1.4

Adrenal mass : liver ratio 1.2 - 2.8

Adrenal mass : liver ratios greater than 3

Adrenal adenoma

Adrenal cancer

Pheochromocytomas


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Right adrenal pheochromocytoma

Left adrenal pheochromocytoma

with central cystic change


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Radionuclide imaging

NP-59 (131I-6-iodomethyl-19-norcholesterol) Uptake of NP-59 : benign lesion (adenoma)

Absence of imaging : non-adenomatous lesion

Need to be given cold iodine 1 week before the study

MIBG (I131 metaiodobenzyl guandine)

Pheochromocytoma


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FNA biopsy

Under CT guidance

Widespread use for the diagnosis of many endocrine lesions

Cannot be used to distinguish adrenal adenomas from carcinomas

Useful in patient with a Hx of cancer and a solitary adrenal mass

Pheochromocytomas : Hypertensive crisis


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Management algorithm for Adrenal incidentaloma


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Management algorithm for Adrenal incidentaloma


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Adrenal surgery


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Choice of procedures

Laparoscopic Adrenalectomy

Lateral Transabdominal Approach

Posterior Retroperitoneal Approach

Open Adrenalectomy

Anterior Approach

Posterior Approach

Lateral Approach


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Laparoscopic Adrenalectomy

First by Gagner (1992)

Less pain, mortality, hospital stay

New gold standard

Indication

Small hormone-secreting adrenal tumor

Samlll virilizing adenomna

Conn syndrome

Cushing syndrome

Incidentaloma larger than 5 cm

Contraindication

Previous surgery

Large adrenal gland (larger than 10-15 cm)

Suspected carcinoma of adrenal gland

Malignancy risk


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Laparoscopic Adrenalectomy: Lateral Transabdominal Approach


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Laparoscopic Adrenalectomy: Posterior Retroperitoneal Approach

More direct access to the adrenal gland

Avoids abdominal adhesions

Bilateral adrenalectomy

Working space is limited vascular control difficulty

Unsuitable for large (>5 cm) lesions


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Transperitoneal VS Retroperitoneal Approach


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Open Adrenalectomy


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Open Adrenalectomy


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Open Adrenalectomy


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Open Adrenalectomy


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Laparoscopic VS open Adrenalectomy


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Thank You

Adrenal Glands Incidental Om A

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