By Dr Dipesh K.K

1. Dr Dipesh

2. Adrenal lesions discovered during
imaging performed for unrelated
reasons.
This entity is the result of
technological advances in imaging
such as CT and MRI and their
widespread use in clinical practice.

4.  The incidence of these lesions identified by CT
scans ranges from 0.4 to 4.4%.

5. Discovery of an adrenal mass raises
three questions .
Is it functioning ?
Is it malignant ?
Is there any indication for surgical
intervention?

6. The diagnostic work up of an
adrenal incidentaloma is aimed
at
 Identifying patients who would
benefit from adrenalectomy

8.  Malignancy is an uncommon cause of adrenal
incidentaloma
 The frequency of primary adrenal carcinoma
is approx. 2 to 5 %
 Another 0.7 to 2.5 % have non adrenal
metastases to the adrenal gland
 The size and imaging characteristics of the
mass may help determine whether the tumor
is benign or malignant.

9. The maximum diameter of the adrenal
mass is predictive of malignancy
Adrenocortical carcinoma were
significantly associated with mass size
;90% being more than 4 cm when
discovered.
Adrenal mass size is also important
because the smaller the adrenal
carcinoma , the better the overall
prognosis.

10. In the report from the National
Italian study group, a 4 cm cutoff
had a 93% sensitivity of detecting
adrenocortical carcinoma , even
though specificity was limited(76%
of masses larger than 4 cm were
benign)
In Mayo Clinic study , all 20 adrenal
carcinomas were between 4 and 6
cm in diameter.

11. Therefore, surgical removal of
unilateral adrenal masses larger
than 4 cm should be considered to
avoid missing adrenal carcinoma,
particularly in young patients.
However, adrenal mass size should
not be used as the only parameter
to guide treatment.

12.  Ultrasound is largely deficient for evaluating
the gland because adrenal glands are so far
from the body’s surface,
 Indeed, the left adrenal often cannot be
visualized with ultrasound.
 CT and MRI with 2-3 mm cuts may allow
prediction of the histologic type of the
adrenal tumor
 which is particularly important in the evaluation
of masses that do not meet the size criterion for
removal.

18.  Chemical shift MRI means signal intensity loss on out-of-
phase imaging when compared to in-phase imaging.
 Signifies the presence of intracellular lipid/fat.
 The lipid content of adenoma causes signal drop out on
MRI.
 However,30% of adrenal adenomas do not show signal
dropout on MRI.
 MRI is diagnostically equivalent to non-contrast CT as both
are equally capable in quantifying intracellular lipid.
 However it is more expensive and not superior to contrast
CT.

19.  Lipid-rich adrenal adenoma (arrow).

20. Benign Adenomas
 Round and homogenous density , small contour
and sharp margination
 Diameter less than 4 cm ,unilateral
 Low unenhanced CT attenuation values(<10 HU)
 Rapid contrast medium washout(10 min after
administration of contrast , an absolute contrast
washout of more than 50%)
 Isointensity with liver on both T1 and T2 weighted
MRI sequences

21. Pheochromocytomas
 Increased attenuation on non-enhanced
CT(>20 HU)
 Increased mass vascularity
 Delay in contrast medium washout(10 min
after administration of contrast , an absolute
contrast washout of less than 50%)
 High signal intensity on T2 weighted MRI
 Cystic and hemorrhagic changes
 Variable size and may be bilateral

22. Adrenocortical carcinoma
 Irregular shape
 Inhomogenous density because of central
areas of low attenuation due to tumor necrosis
 Tumor calcification
 Diameter usually>4cm
 Unilateral location
 High unenhanced CT attenuation values(>20
HU)
 Inhomogenous enhancement on CT with iv
contrast

23.  Delay in contrast medium washout(10
min after administration of contrast,an
absolute contrast washout of less than
50%)
 Hypointensity compared with liver on T1
weighted MRI and high to intermediate
signal intensity on T2 weighted MRI
 High standardized uptake value on FDG-
PET-CT study
 Evidence of local invasion or
metastases.

24. Adrenal Metastases
 Irregular shape and inhomogenous nature
 Tendency to be bilateral
 High unenhanced CT attenuation values(>20
HU) and enhancement with IV contrast on CT.
 Delay in contrast medium washout(10 min
after administration of contrast,an absolute
contrast washout of less than 50%)

25. Isointensity or slighty less intense
than the liver on T1 weighted MRI
and high to intermediate signal
intensity on T2 weighted
MRI(representing an increased water
content)
Elevated standarized uptake value
on FDG-PET scan

27.  Cannot distinguish a benign adrenal mass
from the less common adrenal carcinoma
 Distinguish between an adrenal tumor and
metastatic tumor
 Adrenal biopsy would not be needed if the
patient was already known to have
widespread metastatic disease

31. Most adrenal incidentaloma are non-
functional.
 However ,10-15% secrete excess amounts of
hormones
 In review of all 828 published articles ,
following overall mean percentages of
diagnosis were reported
 Malignant
 Primary 1.9%
 Metastases 0.7%

32. Benign
 Non-functioning-89.7%
 Subclinical cushing’s syndrome-6.4%
 Pheochromocytoma-3.1%
 Primary aldosteronism-0.6%

33.  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.
Campbell_Walsh 10th
edition

34.  Appropriate case detection tests should be performed if the
patient has clinical features that are suggestive of increased
adrenal function.
 However subclinical cushing’s syndrome and
pheochromocytoma are sufficiently common that all patients
with adrenal incidentaloma should be tested for this
disorders.

35.  Subclinical cushing’s syndrome
 Glucocorticoid secretory autonomy without
clinical manifestations of cushing’s syndrome
 Most frequent hormonal abnormality detected in
patients with adrenal incidentalomas
 Clinical manifestations
 Many of the usual stigmata of overt cushing’s
syndrome is lacking
 Patients are likely to have
HTN,dyslipidemia,impaired glucose tolerance or
type 2 DM and evidence of atherosclerosis and
incidence of vertebral fracture.

36.  Diagnosis
 1 mg overnight dexamethasone suppression
test(DST)
 An abnormal suppression is consistent with ACTH-
independent cortisol production
 Clinically significant glucocorticoid secretory
autonomy is confirmed by a post-overnight DST 8 am
serum cortisol concentration >5mcg/dl(>138nmol/l)
 24-hour urinary free cortisol
 serum ACTH concentration
 High dose(8mg) overnight DST.

37.  In a large series of adrenal incidentaloma
study,hormone evaluation in patients with
subclinical cushing’s syndrome shows:
 Low baseline secretion of ACTH in 79%
 Lack of suppressibility of cortical secretion after
1 mg dexamethasone in 73%
 Supranormal 24-hr urinary cortisol excretion in
75%
 Disturbed cortisol circadian rhythm in 43%
 Blunted plasma ACTH responses to CRH in 55%

38.  Pheochromocytoma
 Approx. 3% of adrenal incidentalomas prove to be
pheochromocytoma
 Measurement of plasma fractionated
metanephrines is recommended in patients when
the pre-test probability is high(eg if the mass is
vascular,dense and has slow contrast wash-out)

39.  Aldosteronomas
 Are rare(less than 1%) causes of an adrenal
incidentaloma
 All patient with hypertension and adrenal
incidentalom should be evaluated by
measurements of plasma aldosterone
concentration and plasma renin activity.

41.  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)
Campbell_Walsh 10th
edition

42.  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)
Campbell_Walsh 10th
edition

43.  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 upto the level of adrenal vein.
Campbell_Walsh 10th
edition

44.  Surgical approach to adrenal gland
 LAPAROSCOPIC
 OPEN SERGERY
 ROBOTIC

45.  Laparoscopic 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 is done either by
Transperitoneal Approach or Retroperitoneal Approach.
 Neither approach is superior and both are performed by
surgeons based on their individual surgical preferences.

46.  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

47.  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
surgeons because of the increased risk of
treating an invasive adrenal cortical carcinoma.
Campbell_Walsh 10th
edition

48.  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.

49.  Flank retroperitoneal approach

52.  The 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.

53.  Minimal manipulation of adrenal mass.
 Dissection in the surrounding tissues away
from adrenal glands ( N0 touch technique).
 Ligation of adrenal arteries.
 Ligation of adrenal vein : should be careful
at the right side as vein is short and drain
posteriorly directly in IVC and difficult to
control if injured(torn) during dissection
(called vein of death).

55.  Adrenal masses have become increasing due to
widespread use of sectional imaging.
 CT washout studies are considered the gold
standard for adrenal imaging.
 All adrenal incidentalomas demand a metabolic
evaluation
 DONOT Rush to biopsy (only when limitations of
imaging have been reached).
 Laparoscopic adrenalectomy is the current
standard of care for adrenal lesions
 Annual follow-up for 3 to 4 years is
recommended for metabolically silent.

56. THANK YOU