1. Incidental Adrenal Mass
Rebecca Evangelista, MD

2. Ms. Miller
Ms. 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.

3. CT Scan Ms. Miller

4. History
What 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?

6. What is your Differential Diagnosis?

7. Differential Diagnosis
What types of masses are found in the adrenal gland?

8. Physical Examination
What 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=98.9
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

10. What further studies might
you want at this time?

11. Imaging
MRI weighted image

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:
Functional
Non-functional
Neoplastic
What else do you need to know in order to make the diagnosis?

14. What labs or other studies do you need?

15. Labs ordered, Ms. Miller
CBC
Chem 12 -look specifically at K+
24-hour urine for catecholamines and metanephrines
Plasma DHEA
Low-dose dexamethasone suppression test
What 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 adenoma
2) 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 mass
Initial screening lab work should test for aldosteronoma, cortisol-producing adenoma and pheochromocytoma
Additional 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

23. CT Aldosteronoma

24. What if this were a Pheochromocytoma

25. Pheochromocytoma Discuss pre-operative preparation
Discuss peri-operative concerns

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 3
Recommendation 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 options
Laparoscopic adrenalectomy
Open adrenalectomy
Which 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
Type
Functional
Non-functional
Neoplastic
Size
Side
Left or right
X-ray
OR Choice
Laparoscopic
Open
HAL (Hand-Assisted Laparoscopy)

32. Discussion Primary Adrenal Neoplasm
Non-functioning
Cortical Adenoma
Cyst
Myolipoma
Ganglioneuroma
Hematoma
Functioning
Cortisol, Aldosterone
Pheochromocytoma
Neoplastic
Primary carcinoma
Neuroectodermal
Metastatic
Lung, Kidney, Breast,
GI, Melanoma

33. Discussion 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

34. Management Review
For complete review see 2002 NIH Consensus Statement on Incidental Adrenal Masses

35. QUESTIONS ??????

36. Acknowledgment
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