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Indian Journal of Surgical Oncology
Published in: Indian Journal of Surgical Oncology 1/2017

01-03-2017 | Review Article

Management of Adrenal Masses

Authors: Hattangadi Sanjay Bhat, Balagopal Nair Tiyadath

Published in: Indian Journal of Surgical Oncology | Issue 1/2017

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Abstract

An adrenal mass can be either symptomatic or asymptomatic in the form of adrenal incidentalomas (AIs) in up to 8 % in autopsy and 4 % in imaging series. Once a diagnosis of adrenal mass is made, we need to differentiate whether it is functioning or nonfunctioning, benign, or malignant. In this article, we provide a literature review of the diagnostic workup including biochemical evaluation and imaging characteristics of the different pathologies. We also discuss the surgical strategies with laparoscopy as the mainstay with partial adrenalectomy in select cases and adrenalectomy in large masses. Follow-up protocol of AIs and adrenocortical carcinoma is also discussed.
Literature
1.
Kloos RT, Gross MD, Francis IR et al (1995) Incidentally discovered adrenal masses. Endocr Rev 16:460PubMed
2.
Adler JT, Meyer-Rochow GY, Chen H et al (2008) Pheochromocytoma: current approaches and future directions. Oncologist 13:779CrossRefPubMed
3.
Mansmann G, Lau J, Balk E, Rothberg M, Miyachi Y, Bornstein SR (2004) The clinically inapparent adrenal mass: update in diagnosis and management. Endocr Rev 25:309–340CrossRefPubMed
4.
Young WF Jr (2000) Management approaches to adrenal incidentalomas: a view from Rochester, Minnesota. Endocrinol Metab Clin N Am 29:159–185CrossRef
5.
Young WF Jr (2007) Clinical practice. Incidentally discovered adrenal mass. N Engl J Med 356:601–610CrossRefPubMed
6.
Cawood TJ, Hunt PJ, O’Shea D et al (2009) Recommended evaluation of adrenal incidentalomas is costly, has high false-positive rates and confers a risk of fatal cancer that is similar to the risk of the adrenal lesion becoming malignant; time for a rethink? Eur J Endocrinol 161:513–527CrossRefPubMed
7.
Sawka AM, Jaeschke R, Singh RJ, Young WF Jr (2003) A comparison of biochemical tests for pheochromocytoma: measurement of fractionated plasma metanephrines compared with the combination of 24-hour urinary metanephrines and catecholamines. J Clin Endocrinol Metab 88:553–558CrossRefPubMed
8.
Perry CG, Sawka AM, Singh R, Thabane L, Bajnarek J, Young WF Jr (2007). The diagnostic efficacy of urinary fractionated metanephrines measured by tandem mass spectrometry in detection of pheochromocytoma. Clin Endocrinol (Oxf) 66(5):703–8
9.
Lenders JW, Pacak K, Walther MM et al (2002) Biochemical diagnosis of pheochromocytoma: which test is best? JAMA 287:1427–1434CrossRefPubMed
10.
Sawka AM, Prebtani AP, Thabane L, Gafni A, Levine M, Young WF Jr (2004) A systematic review of the literature examining the diagnostic efficacy of measurement of fractionated plasma free metanephrines in the biochemical diagnosis of pheochromocytoma. BMC Endocr Disord 4:2CrossRefPubMedPubMedCentral
11.
Schwartz GL, Turner ST (2005) Screening for primary aldosteronism in essential hypertension: diagnostic accuracy of the ratio of plasma aldosterone concentration to plasma renin activity. Clin Chem 51:386–394CrossRefPubMed
12.
Mulatero P, Rabbia F, Milan A et al (2002) Drug effects on aldosterone/plasma renin activity ratio in primary aldosteronism. Hypertension 40:897–902CrossRefPubMed
13.
Young WF Jr Primary aldosteronism: renaissance of a syndrome (2007). Clin Endocrinol (Oxf) 66(5):607–18
14.
Song JH, Mayo-Smith WW (2014) Current status of imaging of adrenal gland tumors. Surg Oncol Clin N Am 23:847–886CrossRefPubMed
15.
Lee MJ, Hahn PF, Papanicolaou N et al (1991) Benign and malignant adrenal masses: CT distinction with attenuation coefficients, size and observer analysis. Radiology 179:415–418CrossRefPubMed
16.
Korobkin M, Brodeur FJ, Yutzy GG et al (1996) Differentiation of adrenal adenomas from nonadenomas using CT attenuation values. AJR Am J Roentgenol 166:531–536CrossRefPubMed
17.
Peña CS, Boland GW, Hahn PF et al (2000) Characterization of indeterminate (lipid-poor) adrenal masses: use of washout characteristics at contrast-enhanced CT. Radiology 217:798–802CrossRefPubMed
18.
Caoili EM, Korobkin M, Francis IR et al (2002) Adrenal masses: characterization with combined unenhanced and delayed enhanced CT. Radiology 222:629–633CrossRefPubMed
19.
Blake MA, Kalra MK, Sweeney AT et al (2006) Distinguishing benign from malignant adrenal masses: multi-detector row CT protocol with 10-minute delay. Radiology 238:578–585CrossRefPubMed
20.
Blake MA, Kalra MK, Maher MM et al (2004) Pheochromocytoma: an imaging chameleon. Radiographics 24:S87–S89CrossRefPubMed
21.
Bharwani N, Rockall AG, Sahdev A et al (2011) Adrenocortical carcinoma: the range of appearances on CT and MRI. AJR Am J Roentgenol 196:W706–W714CrossRefPubMed
22.
Rozenblit A, Morehouse HT, Amis ES (1996) Cystic adrenal lesions: CT features. Radiology 201:541–548CrossRefPubMed
23.
Motta-Ramirez GA, Remer EM, Herts BR et al (2005) Comparison of CT findings in symptomatic and incidentally discovered pheochromocytomas. AJR Am J Roentgenol 185:684–688CrossRefPubMed
24.
Song JH, Grand DJ, Beland MD et al (2013) Morphologic features of 211 adrenal masses contrast-enhanced CT: can we differentiate benign from malignant lesions using imaging features alone? AJR Am J Roentgenol 201:1248–1253CrossRefPubMed
25.
Boland GW, Blake MA, Hahn PF et al (2008) Incidental adrenal lesions: principles, techniques, and algorithms for imaging characterization. Radiology 249:756–775CrossRefPubMed
26.
Mayo-Smith WW, Boland GW, Noto RB et al (2001) State-of-the-art adrenal imaging. Radiographics 21:995–1012CrossRefPubMed
27.
Jacques AE, Sahdev A, Sandrasagara M et al (2008) Adrenal phaeochromocytoma: correlation of MRI appearances with histology and function. Eur Radiol 18:2885–2892CrossRefPubMed
28.
Metser U, Miller E, Lerman H et al (2006) 18F-FDG PET-CT in the evaluation of adrenal masses. J Nucl Med 47:32–37PubMed
29.
Kumar R, Xiu Y, Yu JQ et al (2004) 18F-FDG PET in evaluation of adrenal lesions in patients with lung cancer. J Nucl Med 45:2058–2062PubMed
30.
Chong S, Lee KS, Kim HY et al (2006) Integrated PET-CT for the characterization of adrenal gland lesions in cancer patients: diagnostic efficacy and interpretation pitfalls. Radiographics 26:1811–1826CrossRefPubMed
31.
Boland GW, Dwamena BA, Sangwaiya MJ et al (2011) Characterization of adrenal masses by using FDG PET: a systematic review and meta-analysis of diagnostic test performance. Radiology 259:117–126CrossRefPubMed
32.
Shulkin BL, Thompson NW, Shapiro B et al (1999) Pheochromocytomas: imaging with 2-[fluorine-18] fluoro-2-deoxy-D-glucose PET. Radiology 212(1):35–41CrossRefPubMed
33.
Greenblatt DY, Shenker Y, Chen H (2008) The utility of metaiodobenzylguanidine (MIBG) scintigraphy in patients with pheochromocytoma. Ann Surg Oncol 15(3):900–905CrossRefPubMed
34.
Gonias S, Goldsby R, Matthay KK et al (2009) Phase II study of high-dose [131I]metaiodobenzylguanidine therapy for patients with metastatic pheochromocytoma and paraganglioma. J Clin Oncol 27(25):4162–4168CrossRefPubMedPubMedCentral
35.
Welch TJ, Sheedy PF 2nd, Stephens DH et al (1994) Percutaneous adrenal biopsy: review of a 10-year experience. Radiology 193(2):341–344CrossRefPubMed
36.
37.
Casola G, Nicolet V, van Sonnenberg E et al (1986) Unsuspected pheochromocytoma: risk of blood-pressure alterations during percutaneous adrenal biopsy. Radiology 159(3):733–735CrossRefPubMed
38.
Ilias I, Sahdev A, Reznek RH, Grossman AB, Pacak C (2007) The optimal imaging of adrenal tumors: a comparison of different methods. Endocr Relat Cancer 14:587CrossRefPubMed
39.
Hamrahian AH, Ioachimescu AG, Remer EM et al (2005) Clinical utility of noncontrast computed tomography attenuation value (Hounsfield units) to differentiate adrenal adenomas/hyperplasias from nonadenomas: Cleveland Clinic experience. J Clin Endocrinol Metab 90:871CrossRefPubMed
40.
41.
Toniato A, Merante-Boschin I, Opocher G et al (2009) Surgical versus conservative management for subclinical Cushing syndrome in adrenal incidentalomas: a prospective randomized study. Ann Surg 249:388–391CrossRefPubMed
42.
Tsuiki M, Tanabe A, Takagi S et al (2008) Cardiovascular risks and their long-term clinical outcome in patients with subclinical Cushing’s syndrome. Endocr J 55:737–745CrossRefPubMed
43.
NIH state-of-the-science statement on management of the clinically inapparent adrenal mass (“incidentaloma”) (2002). NIH Consens State Sci Statements 19:1–25
44.
Terzolo M, Ali A, Osella G, et al. (1997) Prevalence of adrenal carcinoma among incidentally discovered adrenal masses. A retrospective study from 1989 to 1994. Gruppo Piemontese Incidentalomi Surrenalici. Arch Surg, 132:914
45.
Shen WT, Sturgeon C, Duh QY (2005) From incidentaloma to adrenocortical carcinoma: the surgical management of adrenal tumors. J Surg Oncol 89:186CrossRefPubMed
46.
Barnett CC Jr, Varma DG, El-Naggar AK et al (2000) Limitations of size as a criterion in the evaluation of adrenal tumors. Surgery 128:973CrossRefPubMed
47.
Mantero F, Terzolo M, Arnaldi G et al (2000) A survey on adrenal incidentaloma in Italy. Study Group on Adrenal Tumors of the Italian Society of Endocrinology. J Clin Endocrinol Metab 85:637PubMed
48.
Favia G, Lumachi F, Basso S et al (2000) Management of incidentally discovered adrenal masses and risk of malignancy. Surgery 128:918CrossRefPubMed
49.
Ballian N, Adler JT, Sippel RS, Chen H (2009) Revisiting adrenal mass size as an indication for adrenalectomy. J Surg Res 156:16–20CrossRefPubMed
50.
Brunt LM (2002) The positive impact of laparoscopic adrenalectomy on complications of adrenal surgery. Surg Endosc 16(2):252–257CrossRefPubMed
51.
52.
53.
Assalia A, Gagner M (2006) Adrenalectomy. In: Assalia A, Gagner M, Schein M (eds) Controversies in laparoscopic surgery. Springer, Berlin, pp. 315–356CrossRef
54.
Bhat HS, Nair TB, Sukumar S, Saheed CSM, Mathew G, Kumar GP (2007) Laparoscopic adrenalectomy is feasible for large adrenal masses >6 cm. Asian Journal of surgery 30(1):52–56CrossRefPubMed
55.
56.
Saunders BD, Doherty GM (2004) Laparoscopic adrenalectomy for malignant disease. Lancet Oncol 5:718–726CrossRefPubMed
57.
Porpiglia F, Miller BS, Manfredi M et al (2011) A debate on laparoscopic versus open adrenalectomy for adrenocortical carcinoma. Horm Cancer 2(6):372–377CrossRefPubMed
58.
Creamer J, Mathews BD (2013) Laparoscopic adrenalectomy for cancer. Surg Oncol Clin N Am 22:111–124CrossRefPubMed
59.
Tiyadath BN, Sukumar S, Saheed CS, Hattangadi SB (2007 Oct) Laparoscopic adrenalectomy—is it any different ion phaeochromocytoma and non phaeochromocytoma. Asian J Surg 30(4):244–249CrossRefPubMed
60.
Tiyadath BN, Kalavmpara SV, Sukumar S, Mathew G, Pooleri GK, Prasanna AT, Gopalakrishnan UA, Hattangadi SB (2012 Feb) Bilateral simultaneous laparoscopic adrenalectomy in Cushing’s syndrome: safe effective curative. JEndourol 26(2):157–163CrossRef
61.
Brandao LF, Autorino R, Layder H, Haber GP, Ouzaid I, De Sio M, Perdonia S, Stein RJ, Porpiglia F, Kaouk JH (2014) Robotic versus laparoscopic adrenalectomy: a systematic review and meta-analysis. Eur Urol 65:1154–1161CrossRefPubMed
62.
Kaye DR, Storey BB, Pacak K et al. Partial adrenalectomy: underused first line therapy for small adrenal tumors. J Urol 2010; 184:18, 2010
63.
van Heerden JA, Sizemore GW, Carney JA et al (1984) Surgical management of the adrenal glands in the multiple endocrine neoplasia type II syndrome. World J Surg 8:612CrossRefPubMed
64.
de Graaf JS, Lips CJ, Rutter JE et al (1999) Subtotal adrenalectomy for phaeochromocytoma in multiple endocrine neoplasia type 2A. Eur J Surg 165:535CrossRefPubMed
65.
Lairmore TC, Ball DW, Baylin SB et al (1993) Management of pheochromocytomas in patients with multiple endocrine neoplasia type 2 syndromes. Ann Surg 217:595CrossRefPubMedPubMedCentral
66.
Telenius-Berg M, Ponder MA, Berg B et al (1989) Quality of life after bilateral adrenalectomy in MEN 2. Henry Ford Hosp Med J 37:160PubMed
67.
Madala A, Daugherty M, Bratslavsky G (2015). Partial adrenalectomy—why should it be considered? Urology Practice (2)1–8
68.
Volkin D, Yerran N, Ahmed F, Lankford D, Baccala A, Gupta GN, Hoang A, Pinto PA et al (2012) Partial adrenalectomy minimizes the need for long-term hormone replacement in pediatric patients with pheochromocytoma and von Hippel-Lindau syndrome. J Pediatr Surg 47:2077–2082CrossRefPubMed
69.
Diner EK, Franks ME, Behari A et al (2005) Partial adrenalectomy: the National Cancer Institute experience. Urology 66(1):19–23CrossRefPubMed
70.
Janetschek G, Finkenstedt G, Gasser R et al (1998) Laparoscopic surgery for pheochromocytoma: adrenalectomy, partial resection, excision of paragangliomas. J Urol 160(2):330–334CrossRefPubMed
71.
Walther MM, Herring J, Choyke PL et al (2000) Laparoscopic partial adrenalectomy in patients with hereditary forms of pheochromocytoma. J Urol 164(1):14–17CrossRefPubMed
72.
Al-Sobhi S, Peschel R, Zihak C et al (2002) Laparoscopic partial adrenalectomy for recurrent pheochromocytoma after open partial adrenalectomy in von Hippel-Lindau disease. J Endourol 16(3):171–174CrossRefPubMed
73.
Lee JE, Curley SA, Gagel RF et al (1996) Cortical-sparing adrenalectomy for patients with bilateral pheochromocytoma. Surgery 120:1064CrossRefPubMed
74.
Neumann HP, Bender BU, Reincke M et al (1999) Adrenal-sparing surgery for phaeochromocytoma. Br J Surg 86:94CrossRefPubMed
75.
Neumann HP, Reincke M, Bender BU et al (1999) Preserved adrenocortical function after laparoscopic bilateral adrenal sparing surgery for hereditary pheochromocytoma. J Clin Endocrinol Metab 84:2608PubMed
76.
Ishidoya S, Ito A, Sakai K et al (2005) Laparoscopic partial versus total adrenalectomy for aldosterone producing adenoma. J Urol 174:40CrossRefPubMed
77.
Zeiger MA, Thompson GB, Duh QY et al (2009) The American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons medical guidelines for the management of adrenal incidentalomas. Endocr Pract 15:1CrossRefPubMed
78.
Nambirajan T, Leeb K, Neumann HP et al (2005) Laparoscopic adrenal surgery for recurrent tumours in patients with hereditary phaeochromocytoma. Eur Urol 47(5):622–626CrossRefPubMed
79.
Robotic partial adrenalectomy using indocyanine green dye with near-infrared imaging (2013) The initial clinical experience. Ted B. Manny, Alexandre S. Pompeo, and Ashok K. Hemal UROLOGY 82: 738e742
80.
81.
Fowler AM, Burda JF, Kim SK (2013) Adrenal artery embolization: anatomy, indications, and technical considerations. AJR Am J Roentgenol 201(1):190–201CrossRefPubMed
82.
Wolf FJ, Dupuy DE, Machan JT et al (2012) Adrenal neoplasms: effectiveness and safety of CT-guided ablation of 23 tumors in 22 patients. Eur J Radiol 81(8):1717–1723CrossRefPubMed
83.
Kumar P, Bryant T, Breen D et al (2011) Transarterial embolization and doxorubicin eluting beads transarterial chemoembolization (DEB-TACE) of malignant extra-adrenal pheochromocytoma. Cardiovasc Intervent Radiol 34(6):1325–1329CrossRefPubMed
84.
Barzon L, Scaroni C, Sonino N et al (1999) Risk factors and long-term follow-up of adrenal incidentalomas. J Clin Endocrinol Metab 84:520–526PubMed
85.
Madeville J (2010) Moinzadeh A. Adrenal incidentalomas—AUA update series 29:34–39
86.
Singh PK, Buch HN (2008) Adrenal incidentaloma: evaluation and management. J Clin Pathol 61:1168–1173CrossRefPubMed
Metadata
Title
Management of Adrenal Masses
Authors
Hattangadi Sanjay Bhat
Balagopal Nair Tiyadath
Publication date
01-03-2017
Publisher
Springer India
Published in
Indian Journal of Surgical Oncology / Issue 1/2017
Print ISSN: 0975-7651
Electronic ISSN: 0976-6952
DOI
https://doi.org/10.1007/s13193-016-0597-y

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