case presentation and literature review of adrenal masses

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Case presentation and Review of Assessment and Management of an Adrenal Mass in Urological Practice ,AUA Update Series 2014 ,Lesson 19 Volume 33

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  • Case presentation

    Urology Tuesday meeting

    Anas Hindawi PGY3 Urology ResidentMakassed General HospitalBeirut Arab University

    14/4/2015

  • 24 y.o female previously healthy

    Presentation for gastroenteritis with associated abdominal pain

    P.E : normal PMH : nonePSH : noneAllergy : none

    IV hydration and workup started

  • CBCD : Hg/Hct 13.7/40.2 ,WBC 10.4 ,Neut 62 ,Plt 267Chem 6 : BUN/Cr 0.55/26 ,138/4/105/21Glucose : 93LFTS and lipid panel are all normal CRP : 1FT3 3.7 ,FT4 13.97 ,TSH 1.91H pylori IGg normal U/A : PH 5.5 ,wbc 7-8 ,rbc 2-3

    Chest X ray normal

  • Patient gets improved except for incidental finding on ultrasound abdomen pelvis

  • Parasplenic nodule 3*4 cm corresponding to adrenal gland with left iliac adenomegaly corresponding to the left kidney

  • Next

  • CT abdomen and pelvis with IV contrast

  • Left parasplenic heterogenous mass found to have 11 up to 18 HU with no remarking enhancement

  • Next

  • Plasma Metanephrine 37 ng/L (ref. range
  • Next

  • MRI with gadolinium

  • Next

  • Laparoscopic Left Adrenalectomy

  • Review of Assessment and Management of an Adrenal Mass in Urological Practice

    AUA Update Series 2014Lesson 19 Volume 33Division of Urologic Oncology, Department of Surgical OncologyFox Chase Cancer Center-Temple University Health SystemPhiladelphia, Pennsylvania

  • ADRENAL ANATOMY AND PHYSIOLOGY

  • Adrenal glands are located deep in the retroperitoneum and are essential to life

    Laparoscopic approaches to the adrenal extremely advantageous because of equidistant from all body surfaces

    The capper adrenal glands are located superior to the kidney ,while the cradlers lie medial to the kidney and straddle the renal vessels

    The adrenal glands are almost always found in their orthotopic location in cases of renal agenesis or renal malposition

  • A devastating surgical error is to confuse the tail of the pancreas for the left adrenal gland, as the tissue of these organs intraoperatively can look surprisingly similar

    Given the endocrine function of the glands, blood flow to the adrenal glands is rich

    Approximately 60 separate small arteries enter each gland and stem from 3 main sources

    Generally a single vein drains each adrenal gland

  • The adrenal glands are best conceptualized as 2 distinct organs comprising the adrenal cortex and the adrenal medulla.

    The medulla lies at the center of the adrenal, is innervated by sympathetic fibers and secretes epinephrine (80%), norepinephrine (19%) and dopamine (1%)

    The adrenal cortex is subdivided into 3 regions known as zona glomerulosa, zona fasiculata and zona reticularis

    The hypothalamic-pituitary-adrenal axis regulates cortisol and adrenal androgen secretion, while the renin-angiotensin-aldosterone system controls secretion of aldosterone

  • ADRENAL MASSBy age 70 years up to 7% of individuals will harbor an adrenal mass ,while much more rare in youth ~0.5%

    Defined as a lesion >1 cm from either the cortex or the medulla

    Although the majority of masses are benign and metabolically silent, during every evaluation of an adrenal mass the urologist must risk stratify for presence of malignancy and assess for metabolic activity

  • Cross-sectional imaging with MRI or CT affords excellent visualization of the gland

    The linchpin of adrenal imaging is quantification of intracytoplasmic lipid content of a given tumor, since adrenal adenomas generally contain much larger quantities of intracellular lipid than other adrenal lesions

    Lipid poor adenomas can usually be distinguished from other adrenal pathologies such as pheochromocytomas, carcinoma or metastases using the CT washout study

  • Standard post-contrast CT (1 minute after an iodinated contrast bolus), does not provide meaningful information regarding lipid content of adrenal masses

    MRI does not allow for washout testing, as gadolinium based contrast agents do not harbor dose dependent signal fall-off properties as do iodinated CT contrast agents

    FDG-PET better used for staging non MEN 2 cases with pheochromocytoma than as initial adrenal mass characterization

  • Size of adrenal massAnalysis of large retrospective cohorts of incidentally discovered adrenal lesions revealed that chances of harboring a malignant adrenal mass are strongly linked to tumor size

    Large upper pole kidney tumors leave the renal unit in its orthotopic location, large adrenal masses often displace the kidney

  • Current recommendations advise resection of masses >6 cm that are not radiographically consistent with myelolipoma, since nearly a third of these tumors prove malignant upon resection

    Meanwhile, the 4 cm cutoff is generally reserved for the young and patients without comorbidities

    No improvement in survival for patients with ACC has been noted in the last 2 decades

    Sound clinical judgment that integrates not only tumor size, but also patient age, comorbidity status, tumor growth kinetics and surgical risks should inform clinical decision making to proceed with adrenalectomy

  • Adrenal mass growth kinetics

    Expert consensus advises reimaging of adrenal masses at 6, 12 and 24 months after diagnosis

    Up to 9% of adrenal incidentalomas will grow >1 cm during the first few years of follow-up

  • Adrenal biopsyRarely necessary

    Differentiation between adrenocortical carcinoma and adenoma is rarely possible

    Needle track seeding and hemorrhage have been reported with the latter potentially complicating future adrenalectomy

    Therefore, adrenal biopsy should be pursued only when limitations of imaging and metabolic evaluation have been reached and when the clinical team is certain that the result of biopsy will influence management

  • Metabolic evaluationMore than 10% of adrenal incidentalomas are metabolically active, and all adrenal masses >1 cm should be tested for cortisol and catecholamine hypersecretion

    To rule out hypercortisolemia or Cushing syndrome, the low dose dexamethasone suppression test is used by most practitioners

    Plasma-free metanephrines or 24-hour total urinary fractionated metanephrines are largely equally adequate for initial screening for pheochromocytoma

  • Only patients with an adrenal mass and hypertension require screening for hyperaldosteronism, and Conn syndrome is found in
  • Metabolic evaluation

  • ManagementMetabolically silent adrenal lesions 3 cm can have hormonal hypersecretion upon further testing

    Metabolically silent adrenal lesions require an annual metabolic evaluation for 3 to 4 years after the initial diagnosis

    Reimaging generally should occur at 6, 12 and 24 months after diagnosis to establish tumor growth kinetics