Endo2: Surgical Management Of Adrenal Tumors

Front 1

Adrenal Gland Anatomical Location

Back 1

Between inferior vena cava, kidney, liver, crura of diapraghm on right

Between panceras, crura of diaphragm, and kidney on left

Looks like a tripartite hat

Front 2

Pertinent Questions about an adrenal lesion

Back 2

Functional vs non-functional (Pheochromocytoma, Aldosterone or cortisol producing)

Family History (MEN2 associated with excess catecholamines, minor assoc. with MEN1)

Physical Exam

Labs - serum and urine

Radiology - CT and MRI

Front 3

H&P differences Pheochromocytoma, Aldosterone and cortisol producing tumors

Back 3

Pheochromocytoma - Epi/Norepi raise HR and BP via alpha and beta receptors. PAROXYSMAL effect that present jittery w/ headache.

Aldosterone - BP raises OVER TIME

Cortisol - BP raises over time, moon facies, striae, buffalo hump, HTN, diabetes

Front 4

Labs and Urine differences Pheochromocytoma, Aldosterone and cortisol producing tumors

Back 4

Pheochromocytoma - DO NOT order plasma catecholamines b/c unreliable.

Get 24 hr Metanephrines/normetanephrines which are metabolites in urine. (VMA, metanephrines)

Cortisol - dirunal variation, need 24 hr urine collected separately from catecholamines

Aldosterone - can measure aldosterone and renin in plasma, renin suppressed by elevated aldosterone if lesion is primary so aldosterone: renin ratio is important

Front 5

Most common radiologic study for adrenal masses

Back 5

Contrast enhanced CT best, MRI is less precise but tumors have a higher water content and light up on T2 weighted images

Front 6

Pheochromocytoma Presentation

Back 6

SIGNIFICANT elevated BP with relative dehydration and hemoconcentration (high Hct)

Vague abdominal pain, INTERMITTENT headache, palpitation, sweating, "panic attack" episodes. High urine catechols, VMA and metanephrines

Episodic sweating, dizziness, palpitatoins, headaches, often severe HTN, may have "flash" CHF due to afterload (catecholamine induced CHF)

Fix with alpha blockade

Front 7

Physiology in Pheo, implications in surgery, management

Back 7

Epi acts on alpha 1 receptors to vasoconstrict and elevate BP, kidney then diuresis to reduce and get hemoconcentration and dehydration.

Tachycardia from beta activation

If anesthetize may have vascular collapse b/c dehydrated and die b/c of lowered venous return

Management -
a) Alpha blockade - Phenoxybenzamine (oral) OR phentolamine or nitroprusside (IV) and alpha blockers (-azosin)
b) Hydration - measured by postural BP changes, when BP goes down know that Hct falls and successful prep
c) Telemedicine for preop managment, Get BP 2x week to measure success of prep

Front 8

Aldosterone secreting tumor presentation, differentiating from hyperlasia, Physiology, Management

Back 8

Young age, difficult to control, multi-drug HTN, severe HYPOkalemia

Differentiating: Hyperplasia has BIL gland enlargement usually vs a single gland with a nodule & atrophy with cortical thinning in the non-affected gland (aldosteronoma)

Physiology - High aldosterone, retain Na+ and water, excrete K+, hypokalemic leads to fatigue

Management: Spironalactone (K+ sparing diuretic and aldosterone antagonist), correct potassium, cannot do surgery if severe hypokalemic

Surgical resection. tumor often smaller than pheo due to fact it presents earlier

Front 9

Cushing's Syndrome Presentation, Differentiating from secondary, Physiology, Management

Back 9

Presentation: DM, central obesity, moon facies, stria, buffalo hump

Differentiation: ACTH high if ectopic or pituitary tumor, low if primary. Dexamethasone suppression test

Physiology: Mediated by cortisol, moon facies,

Management: wound healing is primary concern, risk of wound herniation

Surgical resection: laproscopic surgery is preferred

Front 10

Incidentaloma, Management depending on size

Back 10

Adrenal mass found on CT or MRI ordered for other reasons, most commonly liver or kidney cysts

Size:
a) <3cm and looks benign - observe
b) >5cm - surgical resection based on increased adrenocortical cardinoma
c) >3 but <5cm - evaluate risk/benefit analysis - may do multiple imaging or just resect

Front 11

Evaluating non functional adrenal masses and examples

Back 11

Must find if it is symptomatic vs asymptomatic and benign vs malignant

Symptomatic/Benign - ex massive hemangioma - resect b/c symptomatic
Asymptomatic/Benign - adrenal cyst - observation
Symptomatic/Malignant - metastatic lung cancer (commonly goes to adrenal glands and often BIL) - inoperable b/c of organs nearby so chemotherapy
Asymptomatic/malignant - early metastatic cancer, chemotherapy, if isolated disease may be possible to resect, if many sites and invading chemo best

Front 12

Surgical approach to glands

Back 12

place patient on side for laproscopic surgery to shorten distance from flank to gland