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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: Lateral Transabdominal Approach
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Laparoscopic Adrenalectomy: Lateral Transabdominal Approach
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Laparoscopic Adrenalectomy: Lateral Transabdominal Approach
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Laparoscopic Adrenalectomy: Lateral Transabdominal Approach
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Laparoscopic Adrenalectomy: Lateral Transabdominal Approach
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Laparoscopic Adrenalectomy: Lateral Transabdominal Approach
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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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Laparoscopic Adrenalectomy: Posterior Retroperitoneal Approach
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Laparoscopic Adrenalectomy: Posterior Retroperitoneal Approach
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Laparoscopic Adrenalectomy: Posterior Retroperitoneal Approach
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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