2 Ms. MillerMs. Miller, a 52 year-old female, was recently evaluated in the ER for vague complaints of abdominal pain. She was discharged with the diagnosis of gastroenteritis but was called by the radiologist two days later because “there is a mass in the gland above my kidney.” She was advised to see a surgeon.
4 HistoryWhat other aspects of the history of present illness do you want to know?Make a list of at least three pertinent questions.
5 History, Ms. Miller Consider the following: 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?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?
7 Differential Diagnosis What types of masses are found in the adrenal gland?
8 Physical ExaminationWhat specific aspects of the physical exam would you look for?
9 Physical Examination, Ms. Miller Vital Signs: BP=156/89, HR=79, RR=14, T=98.9Appearance: Slightly overweight, well-appearingRelevant problem-focused exam findingsHEENT: anicteric sclera, no lymphadenopathy, no thyromegaly or massGenital-rectal: no masses, normal toneChest: clear bilaterally, good air movementNeuromuscular: grossly normalCV: Rhythm regular, no murmurBreast: no masses, no nipple dischargeAbd: soft, non-tender, no masses, no hepatosplenomegaly, no herniasSkin/Soft Tissue: nonotable findingsRemaining Examination findings non-contributory
10 What further studies might you want at this time?
12 Studies – Results Discussion of imaging study What is the differential diagnosis now?
13 Can you narrow your differential diagnosis? Incidental adrenal masses can be divided into three main categories:FunctionalNon-functionalNeoplasticWhat else do you need to know in order to make the diagnosis?
15 Labs ordered, Ms. MillerCBCChem 12 -look specifically at K+24-hour urine for catecholamines and metanephrinesPlasma DHEALow-dose dexamethasone suppression testWhat type of adrenal mass does each of these specifically test for?
16 Labs ordered, discussion 1) What else would you order if the low-dose dexamethasone test was positive (i.e. the serum cortisol levels were not supressed by low-dose dexamethasone)?2) What else would you order if the patient was hypertensive or hypokalemic?
17 Labs ordered, discussion 1) Plasma ACTH, urine-free cortisol and possible high-dose dexamethasone suppression test cortisol-producing adenoma2) Plasma aldosterone and plasma renin levels aldosteronoma
18 Labs ordered/results, Summary Discussion Every person with a new finding of an incidental adrenal mass, or adrenal incidentaloma, of any size, should be worked-up for a functional massInitial screening lab work should test for aldosteronoma, cortisol-producing adenoma and pheochromocytomaAdditional lab work is done if initial screening lab work is abnormal
19 Scenario 1 Lab results, Ms. Miller All of Ms. Miller’s lab work is normal…what do you recommend?More Studies?Observation?Surgery?Choose one before moving on…
20 Scenario 1 Recommendation for this 3.5 cm non-functional mass …Observation-for incidental adrenal masses less than 4.5 cm with benign radiographic appearance the current recommendation is observation with repeat CT scan in 6 months…if the mass is stable for 12 months than observation can continue
21 Scenario 2, Lab results, Ms.Miller She is hypertensive (BP 156/89), her K+=2.2 and plasma: renin >20…what do you recommend?More studies?Observation?Surgery?Choose one before moving on…
22 Scenario 2 Recommendation for this 3.5 cm functional mass, in this case aldosteronoma …Surgery-Any functional adrenal mass of any size should be excised
26 Scenario 3, Lab results, Ms. Miller All lab values are normal but a second opinion of the CT scan is that the mass has irregular borders…what do you recommend?More studies?Observation?Surgery?Choose one before moving on…
27 Scenario 3Recommendation for this 3.5 cm suspicious appearing mass in an otherwise healthy patient…More studies and Surgery-any non-functional adrenal mass of any size suspicious for malignancy on CT should first prompt focused work-up for a primary malignancy. If the patient is otherwise disease free the affected adrenal gland should be excised
28 What are the surgical options for adrenalectomy?
29 Which do you recommend to Ms. Miller for each individual scenario? Surgical optionsLaparoscopic adrenalectomyOpen adrenalectomyWhich do you recommend to Ms. Miller for each individual scenario?
30 What next? Discussion of suggested interventions Value of 1 intervention over another?What is EB practice in each?
31 Surgical Considerations TypeFunctionalNon-functionalNeoplasticSizeSideLeft or rightX-rayOR ChoiceLaparoscopicOpenHAL (Hand-Assisted Laparoscopy)
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