Adrenal incidentaloma

Agenda• Introduction• Anatomy and physiology• Definition• Incidence• Etiology of adrenal incidentaloma.• History and Examination• Imaging• Biochemical evaluation• Role of biopsy• Management

Mohamed Elgendy

Introduction

• Adrenal masses have become increasing due to widespread use of sectional imaging.

• The urologist is the surgical expert of the retro-peritoneum.

• Urologists must be the leader for clinical evaluation and management of adrenal pathology.

AUA Update 2014Mohamed Elgendy

Anatomy

• The adrenal glands are paired retroperitoneal organs

composed of two embryologically Separate units a cortex

and medulla.

• Adrenal and renal development are separate processes,

adrenal gland development occurs normally in the absence

of ipsilateral renal unit development.

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physiology

Functionally Adrenal Glands Has two Parts ;Adrenal Cortex and Medulla

Adrenal cortex consists of three main zones; zona glomerulosa secrete mineralocorticoid (Aldosterone) .

zona fasciculata secrete glucocorticoid (cortisol).

zona reticularis secrete androgen.

The hypothalamic-pituitary-adrenal axis regulates cortisol and adrenal

androgen secretion, while the renin-angiotensin-aldosterone system

controls secretion of aldosterone.

Adrenal Medulla secretes Epinephrine (80%) Norepinephrine(19%)

under control of autonomic nervous system.

DefinitionAre unsuspected adrenal masses greater than 1 cm in diameter identified on cross-sectional imaging performed for unrelated causes.

Campbell_Walsh 10th edition

Is there any indication for surgical intervention?

Is it functioning ?

Is it malignant ?

3 Questions

History and ExaminationThe main goal of history is to determine if the patient has symptoms or signs suggesting the presence of a functional adrenal mass

HTN, obesity and glucose intolerance

Headache, palpitation, profuse sweating

significant HTN with history of hypokalemia

History of Malignance

History of familiar condition

Cushing syndrome

Pheochromocytoma

Aldosterone producing adenoma

May be metastasis

Pheochromocytoma

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Imaging of Adrenal MassesNumerous imaging modalities can be used to assess both

morphologic and functional features of adrenal masses.

Because adrenal glands are so far from the body’s surface, ultrasound is largely deficient for evaluating the gland. Indeed, the left adrenal often cannot be visualized with ultrasound.

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Imaging of Adrenal MassesComputed Tomography and Magnetic Resonance Imaging;

the cornerstone for adrenal evaluation.

Size, laterality, homogeneity, density, vascularity

(enhancement and washout), and anatomic relationships

can be accurately assessed.

the presence of intracytoplasmic lipid differentiates a

benign adrenal adenoma from other adrenal pathology

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Unenhanced and enhanced CT. Adenomas being lipid rich, an adrenal lesion measuring less than 10

HU on non-contrast images is an adenoma 100% of cases regardless

of the size. Hamrahian 2005

Lipid poor adenomas can measure between 10 and 20 HU, in these

cases contrast scans are used and enhancement is measured at 60 s

and 15 min. Absolute washout of contrast at 15 min (> 95% ) is lipid

poor adenoma .

Masses >6 cm should be considered malignant until proved otherwise.

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Unenhanced and enhanced CT

Unenhanced measurements >10 HU and no contrast wash

out after 15 min usually denote phaeochromocytoma or

adrenocortical carcinoma or metastasis.

Further features suggestive of malignancy include large size,

heterogeneous enhancement, necrosis or invasion of

adjacent organs.

Macroscopic fat enhancement denotes myelolipoma of the

adrenal gland.

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Noncontract CT. Showing Attenuation greater than 10 Hounsfield units (HU).

15 hf

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CT demonstrating enhancement 60 seconds following an intravenous (IV) contrast bolus.

55 hf

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CT revealing attenuation of the lesion 15 minutes after the initial bolus following contrast washout..

This lesion exhibits an absolute percent washout the lesion is a lipid-poor adenoma

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Chemical shift MRIChemical shift means Signal intensity loss on (out-of-phase

sequences) when compared to (in-phase imaging) signifies the

presence of intracellular lipid.

The lipid content of adenoma causes signal dropout on MRI.

30% of adrenal adenomas do not showing signal dropout on MRI.

MRI is largely diagnostically equivalent to non-contrast CT as

both are equally capable in quantifying intracellular lipid.

More expensive and not superior on contrast CT.

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Radiopaedia

Right adrenal lesion - isointense to liver on in phase image

Signal drop in the adrenal lesion on the right side in the out-of-phase image

MRI T1

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Metaiodobenzylguanidine (MIBG) scan

MIBG is an analogue of noradrenaline and it selective

uptake by chromaffin cells in the adrenal

(phaeochromocytoma) or extra-adrenal locations.

MIBG may be helpful in diagnosing and localising recurrent

or metastatic phaeochromocytoma in difficult locations.

Maurea S, 2014Mohamed Elgendy

Is it functioning ?

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Metabolic evaluation.More than 10% of adrenal incidentalomas are

metabolically active.

All adrenal incidentalomas demand a metabolic evaluation

whether symptomatic or not.

Annual follow-up for 3 to 4 years is recommended for

metabolically silent masses; however, de-novo

development of metabolic activity is rare.


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Metabolic evaluation. complete adrenal hormonal evaluation is beyond the capability of most

urologists and should be undertaken by a specialised endocrinologist, but the urologist can easily undertake basic screening evaluation for the following entities.

Hypercortisolism (cushing ); Low-dose dexamethasone suppression test or 24-hour urinary cortisol.

Phaeochromocytoma; 24-hour urinary metanephrines or plasma-free metanephrines

Hyperaldosteronism only If patient is hypertensive; morning plasma aldosterone to renin ratio and plasma morning aldosterone level

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Treatment Radiographic character

Metabolic Activity

Malignant potential

Adrenal Pathology

Adrenalectomy+/- mitotane (chemotherapy)

>10 hf,Lack contrast washout at 15min

50% ACTIVE MALIGNANT Adrenocortical carcinoma

Adrenalectomy if active, if >4 cm

<10 hf, >95% contrast washout at 15min

6 % ACIVE BENGIN Adenoma

No ttt Macroscopic lipid content on ct

none BENIGN Myelolipoma

Adrenalectomy >10 hf,Lack contrast washout at 15min

100% 5% MALIGNANT

pheochromocytoma

Adrenalectomy in young

Well circumscribed, non-enhanced

None 7 % MALIGNANT

Cysts

Adrenalectomy if solitary from lung or kidney

>10 hf,Lack contrast washout at 15min

None MALIGNANT Metastases

Diagnosis after resection

none 10% cortisol 30% MALIGNANT

Oncocytoma (50 cases only)

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Role of Adrenal biopsy

The role for adrenal biopsy has been limited for the following

reasons:

1. Modern imaging affords super diagnostic capabilities.

2. Histologically adenomas cannot be reliably differentiated

from adrenal carcinomas.

3. Adrenal biopsy is not without risk.


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Cont.. Role of biopsyComplications of Biopsy.1. Bleeding is the most common with pneumo-/hemothoraces.2. Needle-track seeding in patients with adrenocortical

carcinoma.3. biopsy, especially if followed by hemorrhage, can complicate

or even prevent laparoscopic resection.

Precaution before biopsypheochromocytoma is metabolically excluded prior to biopsy, as it may result in life-threatening hypertensive crises.


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Can mass be characterizedwith imaging?

Is the massmetabolically active?

Will biopsychange management?

Is adrenocortical carcinomastrongly suspected?

Perform biopsy(be certain pheochromocytoma is ruled

out)

Adrenal mass

No rolefor biopsy

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Cont.. Role of biopsy

In conclusion, adrenal biopsy should be done only when

limitations of imaging have been reached and when the physician are

certain that the result of biopsy will influence management.


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Surgical Indications for Adrenalectomy

1. Functional adrenal mass (• Cortisol hypersecretion •

Pheochromocytoma • Aldosterone hypersecretion)

2. Mass > 4 cm with exception of myelolipoma

3. Mass with imaging findings that are suggestive of

malignancy (lipid-poor, heterogeneous, irregular borders,

infiltrates surrounding structures, Metastasis)


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4. Adrenal incidentaloma that grow greater than 1 cm on

follow-up imaging. 5. Extremely large and/or symptomatic myelolipoma.6. Isolated adrenal metastasis (multidisciplinary decision

making required)7. ACTH-independent macronodular adrenal hyperplasia

(AIMAH)



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8. During radical nephrectomy for renal cell carcinoma if:

Adrenal abnormal or not visualized due to large renal

tumor size on imaging.

Large (≥7 cm) upper pole mass.

Vein thrombus to level of adrenal vein.


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AUA Update 2010

Surgical approach to adrenal gland

Laparoscopy

OPEN SERGERY

ROBOTIC

Laparoscopic approachLaparoscopic adrenalectomy is the current standard of

care for adrenal lesions with the exception of invasive adrenocortical carcinoma or adrenocortical carcinoma with caval thrombus.

Laparoscopic adrenalectomy either done Transperitoneal Approach or Retroperitoneal Approach.

Neither approach is superior and both are performed by surgeons based on their individual surgical preferences.

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OPEN Surgery Indications for Open Surgery

1. Adrenal cortical carcinoma with radiographic evidence of

extra-adrenal tumor invasion of adjacent organs may benefit

from maximal surgical exposure.

2. the extension of adrenal vein tumor thrombus into the

inferior vena cava need a more invasive approach.Campbell_Walsh 10th edition

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OPEN Surgery Cont.. Indications for Open Surgery

3. In developing countries, the resources for laparoscopic surgery

may be lacking, and the open approach will be preferred.

4. Tumor size is a relative contraindication to laparoscopic

surgery. A cutoff size 5 or 6 cm was chosen by many

laparoscopists because of the increased risk of treating an

invasive adrenal cortical carcinoma.Campbell_Walsh 10th edition

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CT scan demonstrating a large right adrenal carcinoma.The right kidney is shifted anteriorly and medially

OPEN Surgery cont..• Adrenal glands are

located deep in upper abdominal cavity.

• Glands are equidistant from all ipsilateral body surfaces, necessitating large open incisions regardless of point of entry.

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OPEN Surgery cont.. Open adrenalectomy can be performed through either a

transperitoneal or retroperitoneal approach.

1. The transperitoneal approaches include midline, subcostal, and

thoracoabdominal.

2. The retroperitoneal approaches include flank and posterior

lumbodorsal.

The advantages of the transperitoneal approaches are better

exposure for larger tumors and excellent access to the great

vessels and retroperitoneum. The main disadvantages are

prolonged ileus and difficult exposure in morbidly obese patients.

OPEN Surgery cont.. Flank Retroperitoneal Approach

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Anterior approach

Subcostal Approach

The anterior approach is useful for

larger tumors and can be extended to

the contralateral side as a chevron

incision for treatment of bilateral lesions

Affords excellent exposure of the great

vessels.

OPEN Surgery cont..• The thoracoabdominal approach is reserved for large

or invasive adrenal carcinomas.• The incision is made through the eighth or ninth intercostal space dividing

the intercostal muscles and costal cartilage and The pleura is entered

• A chest tube is placed before the anterior thorax is closed.

Thoracoabdominal Approach approach

ROBOTIC SURGERYThe advantages of robotics should be the superior

three-dimension visualization and hand-like ability of

the robotic arms to perform the microdissection of the

plane between the adrenal and the great vessels.

The robotic approach has the disadvantage of

increased expense and limited availability compared

to standard laparoscopy.

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Preoperative medical management in patients with pheochromocytoma.

ALPHA BLOCKADE. (Phenoxybenzamine i)s the most common used.

Started with 10 mg twice daily for 7 to 14 days preoperative

develops tachycardiaand/or arrhythmias

Beta blockade ( Atenolol 25 mg twice dailty)(do not start before adequate alpha blockage)

IF BP still poorly controlled

Calcium channel blockade:Amlodipine 10-20 mg daily

Target120-130/80 mm Hg

in seatedPosition 2 days

preoperativeMohamed Elgendy

Surgical principalsMinimal manipulation of adrenal mass.

Dissection should in the surrounding tissues away from

adrenal glands ( N0 touch technique).

Ligation of adrenal arteries.

Ligation of adrenal vein be careful at the right side as vein is

short and drain posteriorly directly in IVC and difficult to

control if torn during dissection called vein of death.

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CASE

45-year-old woman with history of breast cancer and HTN on ttt.

Axial CECT images demonstrate a homogeneous 2.2 x 1.4 cm right adrenal mass that has a density of 28.3 Hounsfield units (HU) after 60 sec . Mohamed Elgendy


Is it functioning?

Is it malignant ?

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Is it malignant ? Breast cancer

Pre contrast showing HF = 5

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Is it functioning?

Hypercortisolism (cushing ); Low-dose dexamethasone suppression test or 24-hour urinary cortisol.

Phaeochromocytoma; 24-hour urinary metanephrines or plasma-free metanephrines

Hyperaldosteronism only If patient is hypertensive; morning plasma aldosterone to renin ratio and plasma morning aldosterone level

HTN

All are with in normal range


NOMANAGMENT

Annual follow-up for 3 to 4 years is recommended for metabolically silent

massesMohamed Elgendy

Take home messages

• All adrenal incidentalomas demand a metabolic evaluation

• CT washout studies are considered the gold standard for adrenal

imaging.

• Annual follow-up for 3 to 4 years is recommended for metabolically

silent.

• Laparoscopic adrenalectomy is the current standard of care for

adrenal lesions.

• DONOT Rush to biopsy (only when limitations of imaging have been

reached).

• Adrenal masses have become increasing due to widespread use of

sectional imaging.

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Thank you

Health & Medicine

Adrenal incidentaloma