Endocrine Surgery Tutorials
Hypercalcemia (High Calcium Levels) and Parathyroid Disease
Neck (Thyroid) Mass
Surgical Approach to the
Surgical Approach for Thyroid
The adrenal glands are two glands situated on either side of the
body above the right and left kidney. Each is approximately 4
centimeters long and 1 centimeter in width. The adrenal glands produce
a variety of important metabolic hormones. A single adrenal gland can
be removed without significant consequence to hormone levels. However,
the patient with both adrenal glands removed will require adrenal
hormone supplementation for the remainder of his or her life.
The patient with an adrenal mass is usually diagnosed in one of two
ways. The first, and more common, is the incidental finding of an
adrenal mass found on a CT scan, obtained for other reasons such as
trauma or backache. The second would be the finding of an adrenal mass
in the evaluation of a patient who has a hormone excess state. This
finding may be indicative of a mass that is over secreting one of its
The evaluation of the patient with an adrenal mass in either
category includes the referral to an endocrine surgeon by their primary
care physician or a referring specialist endocrinologist. The workup
will include a careful family history, in order to evaluate for a
familial endocrine pattern of such masses. Further workup will involve
blood work and usually one or two 24-hour urine collections for
Functioning adrenal tumors are usually one of four
- Aldosterone Secreting
These are usually unilateral tumors of the adrenal cortex,
which secrete a hormone called aldosterone. Elevated aldosterone levels
result in low potassium levels and high blood pressure levels. These
patients have a significant history of high blood pressure and require
These can occur in families (MEN II syndrome) or be
non-familial or sporadic. Such patients classically have a history of
flushing or hypertension. These patients will have their diagnosis
confirmed by 24-hour urinary levels looking for a hypertensive hormone
secreted by the tumor. Familial screening and evaluation for pituitary,
thyroid, and parathyroid dysfunction may be recommended.
- Cushing's syndrome:
In this circumstance, an unexplained stimulus causes the
adrenal glands to secrete too much cortisol or steroids. This can
result in a patient with obesity and hypertension, muscle weakness and
edema. The stimulus may occur from within the adrenal gland itself. The
diagnosis is usually made from the analysis of 24-hour urine for
cortisol levels. If a single lesion causes the abnormality in one of
the adrenal glands then surgical removal is recommended. It may also
occur as a result of a mass or dysfunction elsewhere within the body
such as the pituitary gland (near the brain). If treatment of the
pituitary gland abnormality is not successful, removal of the adrenal
glands may be required.
The patients with this type of adrenal dysfunction are usually
children who present with sex hormone abnormalities and inappropriate
genital growth. A pediatric endocrinologist will evaluate these
patients through CT and urine collections.
The patient with the incidentally discovered adrenal mass must
be carefully evaluated looking at the family history, personal history,
evaluation of the image and by chemical evaluation is mentioned above.
In an asymptomatic mass the physician must consider the possibility of
a very rare form of primary cancer within the adrenal gland. Adrenal
cancer is very deadly and rapidly progressive. Most patients with an
adrenal mass of less than 3 centimeters have very little to worry about
concerning the diagnosis of cancer. These patients should have a
follow-up CT scan within six months and, if any growth or symptoms
develop, consider resection. If a follow-up six-month CT scan confirms
that this is a stable lesion, it may be safely followed without
surgery. In most cases this growth has probably been there many years
prior to its discovery (adrenal adenoma).
The prevailing opinion about
non-functional adrenal masses over 4 to 5 centimeters is that they
should be removed. It is generally noted that the incidence of cancer
is increased in adrenal masses over 4 centimeters in size.
Depending on the size and other features of the adrenal on your x-ray
studies and labs, removal of the adrenal gland may be recommended.
If you desire further information regarding adrenal diseases, we
recom-mend reviewing the “Adrenal Gland” portion of the American Association of
Endocrine Surgeons (AAES) Patient Education Site .