Incidental Adrenal Mass

Incidental Adrenal MassIncidental Adrenal Mass

Rebecca Evangelista, MDRebecca Evangelista, MD

Ms. MillerMs. Miller

Ms. Miller, a 52 year-old female, was recently Ms. Miller, a 52 year-old female, was recently evaluated in the ER for vague complaints of evaluated in the ER for vague complaints of abdominal pain. She was discharged with the abdominal pain. She was discharged with the diagnosis of gastroenteritis but was called by diagnosis of gastroenteritis but was called by the radiologist two days later because “there is the radiologist two days later because “there is a mass in the gland above my kidney.” She a mass in the gland above my kidney.” She was advised to see a surgeon.was advised to see a surgeon.

CT Scan Ms. Miller

HistoryHistory

What other aspects of the history of What other aspects of the history of present illness do you want to know?present illness do you want to know?

• Make a list of at least three pertinent questions.Make a list of at least three pertinent questions.

History, Ms. MillerHistory, Ms. Miller Consider the following:

Characterization of Symptoms: does she have any symptoms at all?

Temporal sequence: has she ever had a CT or ultrasound of her abdomen before?

Alleviating / Exacerbating factors: are there any?

Associated signs/symptoms: HTN, low potassium, recent weight gain, new onset diabetes, palpitations, flushing?

Pertinent PMH: does she have a history of cancer?

Relevant Family Hx: does cancer run in her family? Thyroid cancer, parathyroid cancer, cancer of the adrenal gland?

What is your Differential Diagnosis?

Differential DiagnosisDifferential Diagnosis

What types of masses are found in the What types of masses are found in the adrenal gland?adrenal gland?

Physical ExaminationPhysical Examination

What specific aspects of the physical What specific aspects of the physical exam would you look for?exam would you look for?

Physical Examination, Ms. Miller Vital Signs: BP=156/89, HR=79, RR=14, T=98.9 Appearance: Slightly overweight, well-appearing Relevant problem-focused exam findings

HEENT: anicteric sclera, no lymphadenopathy, no thyromegaly or mass

Genital-rectal: no masses, normal tone

Chest: clear bilaterally, good air movement Neuromuscular: grossly normal

CV: Rhythm regular, no murmur Breast: no masses, no nipple discharge

Abd: soft, non-tender, no masses, no hepatosplenomegaly, no hernias

Skin/Soft Tissue: no

notable findings

Remaining Examination findings non-contributory

StudiesStudies

What further studies might What further studies might

you want at this time?you want at this time?

ImagingImaging

MRI weighted imageMRI weighted image

Studies – ResultsStudies – Results

Discussion of imaging study

What is the differential diagnosis now?

Can you narrow your differential diagnosis?Can you narrow your differential diagnosis?

Incidental adrenal masses can be divided into Incidental adrenal masses can be divided into three main three main categories:: FunctionalFunctional Non-functionalNon-functional NeoplasticNeoplastic

What else do you need to know in order What else do you need to know in order to make the diagnosis?to make the diagnosis?

What labs or other studies do What labs or other studies do you need?you need?

Labs ordered, Ms. MillerLabs ordered, Ms. Miller

• CBCCBC

• Chem 12 -look specifically Chem 12 -look specifically at K+at K+

• 24-hour urine for 24-hour urine for catecholamines and catecholamines and metanephrinesmetanephrines

• Plasma DHEAPlasma DHEA

• Low-dose dexamethasone Low-dose dexamethasone suppression testsuppression test

• What type of adrenal What type of adrenal mass does each of these mass does each of these specifically test for?specifically test for?

Labs ordered, discussionLabs ordered, discussion

1) What else would you order if the 1) What else would you order if the low-dose low-dose dexamethasonedexamethasone test was positive (i.e. the serum test was positive (i.e. the serum cortisol levels were cortisol levels were notnot supressed by low-dose supressed by low-dose dexamethasone)? dexamethasone)?

2) What else would you order if the patient was 2) What else would you order if the patient was hypertensive or hypokalemic?hypertensive or hypokalemic?

Labs ordered, discussionLabs ordered, discussion

1) Plasma ACTH, urine-free cortisol and possible 1) Plasma ACTH, urine-free cortisol and possible high-dose dexamethasone suppression testhigh-dose dexamethasone suppression test cortisol-producing adenoma

2) Plasma aldosterone and plasma renin levels2) Plasma aldosterone and plasma renin levels aldosteronoma

Labs ordered/results,Labs ordered/results, Summary DiscussionSummary Discussion

Every personEvery person with a new finding of an incidental adrenal with a new finding of an incidental adrenal

mass, or mass, or adrenal incidentaloma, , of any size, should of any size, should be worked-up for a functional massbe worked-up for a functional mass

Initial screening lab work should test for aldosteronoma, Initial screening lab work should test for aldosteronoma, cortisol-producing adenoma and pheochromocytomacortisol-producing adenoma and pheochromocytoma

Additional lab work is done if initial screening lab work Additional lab work is done if initial screening lab work is abnormalis abnormal

Scenario 1 Scenario 1 Lab results, Ms. MillerLab results, Ms. Miller

All of Ms. Miller’s lab work is normal…what do you All of Ms. Miller’s lab work is normal…what do you recommend?recommend?

More Studies?More Studies? Observation?Observation? Surgery?Surgery?

Choose one before moving on…Choose one before moving on…

Scenario 1Scenario 1

Recommendation for this 3.5 cm Recommendation for this 3.5 cm

non-functional mass …non-functional mass …ObservationObservation

-for incidental adrenal masses less than 4.5 cm with -for incidental adrenal masses less than 4.5 cm with benign radiographic appearance the current benign radiographic appearance the current recommendation is observation with repeat CT scan recommendation is observation with repeat CT scan in 6 months…if the mass is stable for 12 months in 6 months…if the mass is stable for 12 months than observation can continuethan observation can continue

Scenario 2,Scenario 2,Lab results, Ms.MillerLab results, Ms.Miller

She is hypertensive (BP 156/89), her K+=2.2 and She is hypertensive (BP 156/89), her K+=2.2 and plasma: renin >20…what do you recommend?plasma: renin >20…what do you recommend?

More studies?More studies? Observation?Observation? Surgery?Surgery?



Recommendation for this Recommendation for this

3.5 cm functional mass, in this case 3.5 cm functional mass, in this case aldosteronoma …aldosteronoma …Surgery

-Any functional adrenal mass of any size should -Any functional adrenal mass of any size should be excised be excised

CT AldosteronomaCT Aldosteronoma

What if this were aWhat if this were a PheochromocytomaPheochromocytoma

PheochromocytomaPheochromocytoma

Discuss pre-operative preparationDiscuss pre-operative preparation

Discuss peri-operative concernsDiscuss peri-operative concerns

Scenario 3, Scenario 3, Lab results, Ms. MillerLab results, Ms. Miller

All lab values are normal but a second opinion All lab values are normal but a second opinion of the CT scan is that the mass has irregular of the CT scan is that the mass has irregular borders…what do you recommend?borders…what do you recommend?

More studies?More studies? Observation?Observation? Surgery?Surgery?



Recommendation for this 3.5 cm suspicious Recommendation for this 3.5 cm suspicious appearing mass in an otherwise healthy patient…appearing mass in an otherwise healthy patient…More studies and Surgery

-any non-functional adrenal mass of any size -any non-functional adrenal mass of any size suspicious for malignancy on CT should first suspicious for malignancy on CT should first prompt focused work-up for a primary prompt focused work-up for a primary malignancy. If the patient is otherwise disease free malignancy. If the patient is otherwise disease free the affected adrenal gland should be excisedthe affected adrenal gland should be excised

What are the surgical options for What are the surgical options for adrenalectomy?adrenalectomy?

Surgical optionsSurgical options

Laparoscopic adrenalectomyOpen adrenalectomy

Which do you recommend to Ms. Miller for each Which do you recommend to Ms. Miller for each individual scenario?individual scenario?

What next?

Discussion of suggested interventions Value of 1 intervention over another?

What is EB practice in each?

Surgical ConsiderationsSurgical Considerations

TypeType• FunctionalFunctional• Non-functionalNon-functional• NeoplasticNeoplastic

SizeSize SideSide

Left or rightLeft or right X-rayX-ray

OR ChoiceOR Choice• LaparoscopicLaparoscopic

• OpenOpen• HAL HAL (Hand-Assisted (Hand-Assisted

Laparoscopy)Laparoscopy)

DiscussionDiscussion Primary Adrenal Neoplasm

Non-functioningCortical AdenomaCystMyolipomaGanglioneuromaHematoma

FunctioningCortisol, AldosteronePheochromocytoma

NeoplasticPrimary carcinomaNeuroectodermalMetastatic Lung, Kidney, Breast,

GI, Melanoma

DiscussionDiscussion

Non-operative management of small incidentalomas follow up imaging in 6 months if no change, may increase interval

10 year follow-up 20% will develop hormone secreting tumor

Management ReviewManagement Review

For complete review see 2002 NIH Consensus For complete review see 2002 NIH Consensus Statement on Incidental Adrenal MassesStatement on Incidental Adrenal Masses

www.consensus.nih.gov/2002/2002AdrenalIncidentalomasos021PDF.pdf

QUESTIONS ??????QUESTIONS ??????

Acknowledgment The preceding educational materials were made available through the

ASSOCIATION FOR SURGICAL EDUCATIONASSOCIATION FOR SURGICAL EDUCATION

In order to improve our educational materials wewelcome your comments/ suggestions at:

[email protected]

Documents

Incidental Adrenal Mass