Endocrine Service

Endocrine Surgery Tutorials

Adrenal Mass

Hypercalcemia (High Calcium Levels) and Parathyroid Disease

Neck (Thyroid) Mass

Thyroid Cancer

Surgical Approach to the Adrenal

Surgical Approach for Hyperparathyroidism

Surgical Approach for Thyroid Mass

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 important hormones.

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 hormones.

Functioning adrenal tumors are usually one of four varieties:

1. Aldosterone Secreting Tumors:
   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 potassium supplementation.
2. Pheochromocytoma:
   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.
3. 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.
4. Adreno-genital syndrome:
   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.

Non-functioning adrenal masses:
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 .