Functional Adrenal Adenoma Research Articles

RF09 | PSUN05 Increased Frailty in Patients With Functioning Adrenal Adenomas

Abstract Introduction Frailty is characterized by multisystem function decline related to aging and can be measured using frailty Index (FI). FI is constructed based on the proportion of deficits present in an individual out of the total number of health variables considered. FI in various populations has been shown to predict adverse health outcomes. We aimed to determine the impact of hormone excess on frailty in a prospective cohort of patients with adrenal adenomas. Methods We conducted a multicenter prospective observational study of adult patients with adrenal adenomas and referent subjects without adrenal disorders (Jan 2019-Dec 2021). Adrenal adenomas comprised non-functioning adrenal adenomas (NFA), adenomas with mild autonomous cortisol secretion (MACS), defined as dexamethasone suppression test (DST)>1.8 mcg/dL, Cushing syndrome (CS), and primary aldosteronism (PA). FI was calculated as a sum of 47 variables (20 comorbidities, 13 symptoms, 14 activities of daily living) divided by 47.1 Frailty was defined as FI>0.25. In a subset of patients (n=176), functional measurements (handgrip strength, timed up and go test, gait speed) were performed and compared to FI. Results Of 233 patients (72.1% women), 71 were diagnosed with NFA (median age 64.5 years), 108 with MACS (median age 60.7 years), 11 with CS (median age 58.0 years), 46 with PA (median age 52.4 years), and 33 were referent subjects (median age 51.3 years). When compared to referent subjects, age- and sex-adjusted frailty prevalence was highest in CS (OR 29, 95%CI 4.3-202), followed by MACS (OR 16, 95%CI 3.5-73.7), and PA (OR 11.7, 95%CI 2.4-56), but not in patients with NFA (OR 5.1, 95%CI 0.99-25.8). Compared to patients with NFA, age- and sex-adjusted frailty prevalence was higher in CS (OR 5.8, 95%CI 1.4-24.4) and in MACS (OR 3.2, 95%CI 1.5-6.7), but not in PA (OR 2.3, 95%CI 0.9-6.1) group. Subgroup-analysis based on DST demonstrated a similar increase in age- and sex-adjusted frailty prevalence in patients with DST>5 mcg/dL (OR 3.1, 95%CI 1.2-8.2) and DST 1.9-5 mcg/dL (OR 3.3, 95%CI 1.5-7.4) when compared to patients with DST<1.8 mcg/dL. Higher FI was associated with lower handgrip measurement (P<0.0001), longer time during timed up and go test (P <0.0001), and decreased gait speed (P<0.0001). Conclusions Patients with functional adrenal adenomas are more likely to be frail. In patients with MACS, the prevalence of frailty was not associated with the degree of DST abnormality. FI correlated with currently validated but more cumbersome functional measurements and is a valuable tool that could be easily used in clinical practice and help individualize management decisions in patients with adrenal adenomas. 1 Singh S et al. Frailty in Patients With Mild Autonomous Cortisol Secretion is Higher Than in Patients with Nonfunctioning Adrenal Tumors. JCEM 2020 Presentation: Saturday, June 11, 2022 1:30 p.m. - 1:35 p.m., Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

PSAT009 Cushing's Syndrome Developing 42 Years After Successful Treatment for Metastatic Adrenocortical Carcinoma

Abstract Introduction ACC is a rare malignancy with poor prognosis. ACC is associated with CS in about 10% of the cases. Herein we report a case of a patient with metastatic ACC who developed contralateral functional adrenal adenoma causing Cushing's syndrome 42 years later. Clinical Case A 72-year-old female presented for evaluation of right adrenal incidentaloma, measuring 4.4×3 cm, on CT abdomen and pelvis (CTAP), done as part of the evaluation for hip pain. In addition to the adrenal incidentaloma, a large left adnexal mass (8×7 cm) was also observed. Her past medical history was significant for left adrenal ACC diagnosed at the age of 30, The patient's initial presentation included virilization and menstrual abnormalities. Laboratory evaluation revealed hyperandrogenism and hypercortisolism. There was no evidence of metastatic disease, and the patient was managed surgically (total left adrenalectomy) with normalization of laboratory abnormalities and resolution of symptoms. Four years later, patient pulmonary metastasis were observed in a surveillance scan and the patient underwent wedge resection and chemotherapy. The patient did not have any evidence of recurrent disease thereafter. At the current presentation, there were no symptoms or signs of adrenal hormone excess. Hormonal workup revealed borderline elevation of plasma metanephrines, with normal 24 h urinary metanephrines and catecholamines. DHEA-S and testosterone levels, as well as other androgens, were normal. 1 mg dexamethasone suppression (DST) was abnormal, with cortisol of 5.5 mcg/dL 8 h after dexamethasone administration (normal <1.8 mcg/dL). High dose DST was repeatedly abnormal, with cortisol levels at 4.0 and 4.4 mcg/dL (normal <1.8 mcg/dL). AM cortisol was elevated, at 23.4 mcg/dL (normal 4-22 mcg/dL) with ACTH at 12 pg/mL (normal <45 pg/dL). 24 h urinary free cortisol (UFC) was repeatedly elevated at 123.2 and 83.8 mcg/d (normal <45.0 mcg/d). CA 125 was normal. As there are case reports of ectopic Cushing's syndrome related to ovarian malignancies, and the patient had a large adnexal mass, adrenal and ovarian vein sampling was performed. Cortisol levels were higher in the right adrenal vein compared to the periphery, and the gradient was normal for the left ovarian vein. The right ovary was not visualized, and it was not possible to catheterize the right ovarian vein. Whole body FDG scan revealed intermediate uptake by right adrenal mass and normal uptake by left adnexal mass. Based on these results, it was determined that the right adrenal was the source of excess cortisol, and the patient underwent laparoscopic right adrenalectomy. Pathology evaluation showed adrenal adenoma, without evidence of ACC. The patient was started on physiologic replacement doses of hydrocortisone and fludrocortisone. The patient has been doing very well clinically. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

CT-based Abdominal Adipose Tissue Area Changes in Patients Undergoing Adrenalectomy Due to Cushing's Syndrome and Non-functioning Adenomas.

The majority of Cushing's syndrome (CS) cases constitute patients with functional adrenal adenomas. In adrenal CS, visceral adipose tissue (VAT) area, VAT/subcutaneous adipose tissue (SAT), and VAT/total adipose tissue (TAT) ratios are expected to decrease in response to adrenalectomy, although no change is expected in non-functioning adrenal adenomas (NFA). To evaluate the changes in VAT, SAT, TAT areas and VAT/SAT, VAT/TAT ratios using computed tomography (CT) in patients who underwent adrenalectomy due to adenomas. Preoperative and postoperative CT of 32 patients (16 with CS and 16 with NFA) were retrospectively evaluated. The VAT, SAT, TAT areas were obtained from CT at the level of L1-2 intervertebral disc space, and the VAT/SAT, VAT/TAT ratios were calculated. The postoperative parameter changes in both groups were evaluated compared to the preoperative values. The level of statistical significance was considered as p<0.05. The time interval between preoperative and postoperative CT measurements were 10.37 months (6-17) in CS and 9.75 months (7-15) in NFA groups (p=073). Preoperative CT indicated that the patients with CS had larger VAT and TAT areas (p=0.03, p=0.02) but SAT remained unchanged (p=0.08). However, postoperative CT revealed that there was no difference between the two groups in terms of VAT, TAT, and SAT areas (p=0.87, p=0.36, p=0.14). Postoperatively, in patients with CS, there was a decrease in VAT and TAT areas (p=0.01 for both) and VAT/SAT and VAT/TAT ratios (p=0.03, p=0.02) but SAT remained unchanged (p=0.10). In patients with NFA, no change was detected in the postoperative SAT, TAT, and VAT areas (p=0.12, p=0.40, p=0.99) or the VAT/SAT and VAT/TAT ratios (p=0.38, p=0.62). Adrenalectomy is an effective treatment method leading to a decrease in the VAT, TAT areas, and VAT/SAT and VAT/TAT ratios in patients with cortisol producing adrenocortical adenoma. Thus, CT facilitates quantitative demonstration of the changes while evaluating the response of these patients to treatment.

Aryl hydrocarbon receptor Interacting Protein (AIP) status in a functional adrenal adenoma occurring in a patient with a germline AIP mutation

Aryl hydrocarbon receptor Interacting Protein (AIP) status in a functional adrenal adenoma occurring in a patient with a germline AIP mutation

Seizure and coma secondary to Conn\u2019s syndrome: a case report

BackgroundConn’s syndrome is a curable condition if identified properly. It is characterized by autonomous secretion of aldosterone from the adrenal gland cortex. Its morbidity is related to the increased risk of cardiovascular diseases.Case presentationWe report the case of a 48-year-old man of African descent presenting with generalized tonic-clonic seizure and coma secondary to hypertensive encephalopathy. A biochemical evaluation revealed a very high aldosterone level and an undetectable renin level, both are compatible with primary aldosteronism. The presentation of the following confirms the diagnosis of primary aldosteronism: spontaneous hypokalemia, an undetectable renin level, and a high aldosterone level. Abdominal computed tomography revealed a left adrenal adenoma. Adrenal venous sampling confirmed lateralization of aldosterone excretion from the left adrenal gland. Our patient underwent left laparoscopic adrenalectomy that confirmed a left functional adrenal adenoma. After 12 months of follow up, his hypertension was controlled on only one antihypertensive drug which was down from four drugs preoperatively.ConclusionConn’s syndrome, in this case, was complicated by coma secondary to seizure. Adrenalectomy normalized the hypokalemia and improved resistant hypertension. Potassium supplementation and several antihypertensives were discontinued as our patient became normokalemic and normotensive on one antihypertensive agent.

SUN-158 Testosterone and Cortisol Secreting Large Adreno- Cortical Adenoma

Background: Functional adrenal adenomas most commonly secrete cortisol or aldosterone. Secretion of multiple hormones is commonly seen in adrenocortical carcinomas and is rare in benign adrenal adenomas. We present a case of a patient with a 6 cm benign adrenal adenoma that was secreting both cortisol and testosterone.Clinical case: A 44-year-old Caucasian female with past medical history of Grave’s disease, hypertension, prediabetes and hyperlipidemia presented with hirsutism and weight gain. Physical exam was suggestive of cushing’s disease with elevated blood pressure, hirsutism, supraclavicular fullness, moon facies, facial plethora, dorsocervical fat pad and abdominal striae. Further workup revealed elevated testosterone level of 152ng/dL (9-55ng/dl) and elevated androstenedione level of 2.520ng/ml (0.130–0.820 ng/ml). DHEA 0.741 ng/ml (0.630–4.7ng/ml) and DHEAS 65ug/dl (32-240ug/dl) were both within reference range. The 24-hour urine free cortisol was also elevated at 107.1ug/gram of creatinine (< 24 ug/gram of creatinine) with an undetectable ACTH level of < 5 pg/ml indicating adrenal source of Cushing’s syndrome. CT abdomen and pelvis with and without contrast revealed a 6.3 x 5.2 x 5.6 cm left adrenal mass which measured 22 Hounsfield units (HU) on non-contrast imaging, 85 HU on 70 second imaging and 48 HU on 15 min delayed phase. Calculated percent relative washout was 43.5 % and absolute washout was 59.4 %. There was another 1.1 cm low density nodule on left adrenal genu. The right adrenal gland also had a 1.2 cm low density nodule with 0 HU on all phases compatible with a lipid rich adenoma. Patient then underwent left open adrenalectomy. Pathology revealed a 6 cm adrenocortical adenoma. There was no tumor invasion into adjacent sites, no vascular invasion or tumor necrosis noted. MIB1 index was <1 %. Patient had resolution of hypertension and prediabetes after the surgery. Her cortisol and androgen levels also normalized. Biochemical follow up 6 months post-surgery has not demonstrated any increase in cortisol or androgen levels.Conclusion: Both androgen and cortisol hypersecretion can cause severe hyperandrogenism and virilization but these hormones are commonly secreted in isolation in functional adrenal adenomas. Adrenal masses co-secreting androgen and cortisol are usually indicative of adrenocortical cancer. In this rare case report, both of these hormones were secreted by a unilateral adrenal adenoma, with resolution of symptoms and normalizing of androgen and cortisol levels post left adrenalectomy.

SUN-181 A Case of Metastatic Merkel Cell Carcinoma Within a Cortisol-Producing Adrenal Adenoma

Introduction:Metastasis within another tumor is rare, and exceedingly more rare within a functional adrenal adenoma. Merkel cell carcinoma (MCC) is an aggressive and rare neuroendocrine carcinoma of the skin. We present a patient with history of MCC who presented with an adrenal mass, found to be metastatic MCC within a cortisol-producing adrenal adenoma.Case description:54 year old male with a history of type 2 diabetes, hypertension, MCC of right thigh, presented for adrenal mass. He was initially evaluated in the ER for severe abdominal pain for 4 days. He had a CT abdomen done, which showed 6cm right adrenal mass with extensive fat and soft tissue component within it. Hounsfield units within solid area measured up to 47 units, and surrounding area measured -3 Hounsfield units.His history was significant for MCC of right thigh, type 2 diabetes, HTN, obesity and OSA. Pathology from MCC resection showed no evidence of invasion and clear margins, but he did have microscopic focus on inguinal lymph node biopsy. His PET scan was negative except for low uptake in a 6cm right adrenal lesion that was considered benign-appearing. He completed radiation therapy to right thigh and groin.Physical exam was notably negative for any cushingoid features. Aldosterone, renin and plasma metanephrines were normal. Cortisol after dexamethasone suppression test was elevated, and ACTH and DHEAS were low, raising suspicion of Cushing’s syndrome. He had right adrenalectomy and was then started on steroid replacement. Pathology showed adrenocortical adenoma with a 2cm well-circumscribed mass within the adenoma positive for metastatic MCC with lymphovascular invasion. ACTH stimulation testing was performed at follow up after holding hydrocortisone for over 24 hours, and was consistent with suppression of glucocorticoid axis in the contralateral adrenal gland.Discussion:MCC and metastasis within a functional adrenal tumor are both rare occurrences. Our patient had positive regional lymph node involvement at the time of diagnosis, and although the initial PET scan was interpreted as showing an benign adrenal adenoma, it is likely that this represented distant metastasis. Labs indicated that the surrounding adenoma was likely cortisol-producing. To our knowledge, this is the first case reported of metastatic MCC within a functional adrenal adenoma.

SAT-196 The Use of 11C-metomidate PET-CT to Detect Unilateral Primary Hyperaldosteronism

BackgroundIdentifying causative adrenal lesions presents a significant diagnostic burden for physicians and radiologists. We describe the use of radiolabelled metomidate to lateralise primary hyperaldosteronism.Case presentationA 52-year old Chinese man with a 5-year history of hypertension was referred for hypokalemia [K 2.7 mmol/L (3.6 - 5.0)]. He had been on Telmisartan 80 mg and Amlodipine 10 mg daily and blood pressure at home ranged 110-120 / 70-80 mmHg. There was no history of poor oral intake, persistent diarrhea or vomiting, and he was not on any other prescription or alternative medications. There was no significant family history of hypertension or sudden cardiac death. Clinic blood pressure was 140/84 mmHg. There were no features suggestive of Cushing’s syndrome.Repeat biochemical tests confirmed hypokalemia (K 3.1 mmol/L), and associated raised bicarbonate 37.3 mmol/L [19 - 29]. Magnesium and creatinine were normal. Aldosterone-renin Ratio was elevated at 8.1 (serum Aldosterone 611 pmol/L [97.3 - 834.0], active renin 2.7 pg/ml [1.8 – 59.4]). Post-saline infusion, non-suppressible serum aldosterone levels of 1137 pmol/L was demonstrated, consistent with autonomous aldosterone production.A computed tomography of the adrenal revealed a 2.3 cm x 1.9 cm nodule on the left adrenal gland consistent with lipid rich adenoma.Adrenal vein sampling (AVS) under continuous synacthen infusion was performed. Adrenal to peripheral cortisol ratio was ≥10 for either adrenal veins, confirming cannulation of the adrenal veins. Aldosterone-cortisol ratios showed lateralization to the left adrenal gland (lateralization ratio of 10.35). There was contralateral suppression of the right adrenal gland with ratio of 0.41. 11C-Metomidate PET-CT scan demonstrated a maximum standardised uptake value (SUVmax) of 26.8 over the left adrenal nodule, while the SUVmax of the right adrenal gland was 16.2. Ratio of the left to right adrenal gland SUVmax was 1.65 (above the threshold of 1.25); and was concordant with AVS. This confirmed that the patient had a left functional adrenal adenoma responsible for hyperaldosteronism.Our patient underwent a left adrenalectomy, and histology was consistent with adrenal cortical adenoma. Prior to surgery he required 72 mmol/l of potassium supplementation daily to maintain K levels of 3.3 – 4.0 mmol/L. Two weeks post-operatively, he was normokalemic (K 4.9 mmol/L) without potassium supplementation. Serum aldosterone normalized to 159.3 pmol/L (active renin 9.3 pg/ml). Blood pressure is well controlled on amlodipine 5mg daily.ConclusionTargeted molecular imaging such as 11C-Metomidate PET-CT could aid localisation of functional adrenal disease to guide definitive surgical management. In the future, this could obviate the need for invasive and technically complex procedures like AVS.

Interleukin-6 increases adrenal androgen release by regulating the expression of steroidogenic proteins in NCI-H295R cells.

The purpose of this study was to investigate the potential mechanism of interleukin-6 (IL-6) on the stimulation of excessive androgen secretion in human NCI-H295R adrenocortical cells. We performed transcriptome sequencing of cancer and paracancerous tissues obtained from functional adrenal cortical adenomas. The secretion of dehydroepiandrosterone sulfate (DHEAS) in NCI-H295R cells was detected by a chemiluminescence assay. The expression of messenger RNA (mRNA) was detected by real-time polymerase chain reaction and that of protein was detected by western blotting. The expression of secretogranin II (SCG2) and IL-6 were significantly increased in cancer tissues. Upregulation of mRNA and protein levels of AKR1C3, CYP11A, CYP17A1, 3βHSD, and SULT2A1 was observed after stimulation with IL-6. IL-6 could also increase the expression of StAR mRNA and proteins. Our results suggest that IL-6 can promote androgen secretion by regulating the expression of genes related to androgen pathways.

ADRENAL ADENOMA WITH AUTONOMOUS CORTISOL SECRETION ACCOMPANIED BY HOMOLATERAL RENAL CELL CARCINOMA: A CASE REPORT.

Patients with renal malignancies present high risk of adrenal hyperplasia and adenoma, and part of these are primary lesions, mostly non-functional. Here we presented a case diagnosed as primary adrenal adenoma with autonomous cortisol secretion accompanied by homolateral renal cell carcinoma. A 79-year-old woman was referred for evaluation of a left adrenal mass, with a past medical history of severe hypertension, diabetes, and hyperlipidemia. On examination, no clinical signs of cushingoid features were found. Biochemical measurements showed plasma cortisol was 12.77 μg/dL and was not suppressed by 1 mg dexamethasone (DXM) overnight test (13.6 μg/dL). The contrast CT scan presented a 2.2 cm diameter adrenal mass and revealed, unfortunately, a hyperdense mass at the middle-upper pole of the left kidney. Laparoscopic nephrectomy with left adrenalectomy was performed and pathological examination indicated a final diagnosis of benign adrenocortical adenoma and renal clear cell carcinoma. At 2 months postoperatively, without replacement treatment of cortisol, a recovery of circadian rhythm of cortisol secretion was detected, indicated recovery of the hypothalamic-pituitary-adrenal axis. Patients with renal cancer might be accompanied with functional adrenal adenoma. Therefore, screening for adrenal function should be recommended in patients with renal tumors and/or adrenal incidentaloma.

Laparoscopic Partial versus Total Adrenalectomy in Nonhereditary Unilateral Adrenal Masses

Objective: To compare the surgical outcomes and clinical improvement 1 year after laparoscopic partial and total adrenalectomy for the treatment of patients with nonhereditary unilateral functional adrenal adenomas. Material and Methods: From March 2016 to January 2018, we performed 15 laparoscopic partial adrenalectomy (LPA; Group 1) and 25 laparoscopic total adrenalectomy (LTA; Group 2) procedures. The key points reside in adenoma identification, preservation of the remaining glandular parenchyma, and its blood supply with dissection in the space between the adenoma and the normal parenchyma. The operative and clinical outcomes were compered. Results: The mean age of the patients was 45.1 (17–69) years and the median follow-up was 15 (12–26) months. Operative time, blood loss, and hospital stay were similar between the groups. No major perioperative and postoperative complications occurred. After surgery, all patients had resolution of their symptoms, with no patient in Group 1 requiring steroid replacement. However, a patient in Group 2 required steroid replacement therapy. On postoperative imaging, no residual and recurrent mass was detected. Conclusions: Our results showed that LPA is safe and feasible, and has similar therapeutic results compared with LTA in patients with a nonhereditary hormonally active unilateral adrenal mass. Furthermore, LPA can obviate the need for steroid replacement in these patients.

Diagnostic efficacy of 18F-FDG PET/CT in patients with adrenal incidentaloma.

BackgroundThe management of adrenal incidentaloma is still a challenge with respect to determining its functionality (hormone secretion) and malignancy. In this light, we performed 18F-FDG PET/CT scan to assess the SUVmax values in different adrenal masses including Cushing syndrome, pheochromocytoma, primary hyperaldosteronism and non-functional adrenal adenomas.MethodsTotal 109 (73 F, 36 M) patients with adrenal mass (incidentaloma), mean age of 53.3 ± 10.2 years (range, 24–70) were screened by 18F-FDG PET/CT. Data of 18F-FDG PET/CT imaging of the patients were assessed by the same specialist. Adrenal masses were identified according to the calculated standardized uptake values (SUVs). Clinical examination, 24-h urine cortisol, catecholamine metabolites, 1-mg dexamethasone suppression test, aldosterone/renin ratio and serum electrolytes were analyzed.ResultsBased on the clinical and hormonal evaluations, there were 100 patients with non-functional adrenal mass, four with cortisol-secreting, four with pheochromocytomas and one with aldosterone-secreting adenoma. Mean adrenal mass diameter of 109 patients was 2.1 ± 4.3 (range, 1–6.5 cm). The 18F-FDG PET/CT imaging of the patients revealed that lower SUVmax values were found in non-functional adrenal masses (SUVmax 3.2) when compared to the functional adrenal masses including four with cortisol-secreting adenoma (SUVmax 10.1); four with pheochromcytoma (SUVmax 8.7) and one with aldosterone-secreting adenomas (SUVmax 3.30). Cortisol-secreting (Cushing syndrome) adrenal masses showed the highest SUVmax value (10.1), and a cut-off SUVmax of 4.135 was found with an 84.6% sensitivity and 75.6% specificity cortisol-secreting adrenal adenoma.ConclusionsConsistent with the similar studies, non-functional adrenal adenomas typically do not show increased FDG uptake and a certain form of functional adenoma could present various FDG uptake in FDG PET/CT. Especially functional adrenal adenomas (cortisol secreting was the highest) showed increased FDG uptake in comparison to the non-functional adrenal masses. Therefore, setting a specific SUVmax value in the differentiation of malignant adrenal lesion from the benign one is risky and further studies, including a high number of functional adrenal mass are needed.

Utility of Adrenal vein sampling (AVS) in the investigation of functional bilateral adrenal adenomas

Utility of Adrenal vein sampling (AVS) in the investigation of functional bilateral adrenal adenomas

131Iodine-6-beta-iodomethyl-norcholesterol(Norchol) SPECT-CT as an alternative to adrenal venous sampling for assessment of functional cortical adrenal adenomas

131Iodine-6-beta-iodomethyl-norcholesterol(Norchol) SPECT-CT as an alternative to adrenal venous sampling for assessment of functional cortical adrenal adenomas

Evolution of a surgical service for adrenal pathology and impact of surgical intervention on resistant hypertension

An insight into the impact of adrenalectomy on the management of hypertension is helpful in counselling patients when deciding on surgical intervention. We prospectively studied the outcome after surgical intervention for proven functional adrenal adenomas, particularly in regard to post-operative requirement of antihypertensive medications. All patients were prospectively logged onto a comprehensive database, which allowed subsequent long-term follow-up. Account was taken of morbidity encountered. A total of 77 patients (78 adrenal glands) underwent adrenal surgery between 1995 and 2013. In all, 44 patients (44/77) had proven functional adenomas, phaeochromocytoma (15/44, 34 %), Conn’s (25/44, 56 %), Cushing’s 4 (4/44, 10 %). A minimum follow-up of 12 months revealed all patients to have a reduction in their disease-specific medication with 75 % Cushing’s, 72 % Conn’s and 60 % phaeochromocytoma patients medicine free. Despite the potential for functioning adenomas to produce irreversible change, the intervention of adrenalectomy appears to be beneficial in the vast majority of patients with at least half independent of antihypertensive medication. A reduction in morbidity was demonstrated as experience increased.

Adrenal incidentaloma: A puzzle for clinician

An adrenal incidentaloma (AI) is a puzzle for clinician. In the era of widespread use of CT and MRI, it is becoming an increasingly frequent diagnosis. A detailed list of investigations is ordered to diagnose pathology responsible for AI. Most likely etiology of AI is pathology of AI is benign non-functional adenoma. But looking to the need of specific preoperative preparation for functional adrenal adenoma and importance of early diagnosis in adrenal carcinoma, a complete workup is essential. CT scan of adrenals with contrast gives maximum information about nature of lesion. In general, a lesion more than 6cm or a functioning AI or tumor signal intensity of more than 10HU on unenhanced image, significant enhancement on contrast and deenhancement in signal intensity of less than 50% is suggestive of carcinoma and must be removed. Those AI which are left for observation, also needs regular testing and if found functional on subsequent follow-up or if their size enlarge, they must be removed.

Functional adrenal adenoma in a pregnant woman with a 32 week gestation scheduled for cesarean section

The coexistence of Cushing syndrome and pregnancy is rare. Diagnosis is difficult because pregnancy can be accounted for signs and symptoms of hypercortisolism. Ideally, the treatment is surgical, though it implies a significant rise in morbidity and mortality for both the mother and the fetus. This is due to the increased number of complications such as hypertension, pre-eclampsia, gestational diabetes, abortion and preterm delivery. We present the case of a primiparous patient with a 32 week gestation and Cushing syndrome secondary to a functional adrenal adenoma who has been scheduled for a caesarean section.

Adenoma suprarrenal funcional en gestante de 32 semanas programada para cesárea

The coexistence of Cushing syndrome and pregnancy is rare. Diagnosis is difficult because pregnancy can be accounted for signs and symptoms of hypercortisolism. Ideally, the treatment is surgical, though it implies a significant rise in morbidity and mortality for both the mother and the fetus. This is due to the increased number of complications such as hypertension, preeclampsia, gestational diabetes, abortion and preterm delivery. We present the case of a primiparous patient with a 32 week gestation and Cushing syndrome secondary to a functional adrenal adenoma who's been scheduled for a caesarean section.

Radiofrequency Ablation for Benign Aldosterone-Producing Adenoma

To evaluate the safety and efficacy of radiofrequency ablation (RFA) in treating primary aldosteronism (PA) due to aldosterone-producing adenoma (APA). Radiofrequency ablation is an established technique for treating malignant solid organ neoplasm. Its application on benign functional adrenal adenoma has never been prospectively described. We prospectively evaluated a patient cohort with computed tomography (CT)-guided percutaneous RFA performed on functional APA of size 4 cm or less. Treatment success was defined as complete tumor ablation on follow-up CT scan plus normalization of serum aldosterone-to-renin ratio (ARR) at 3 to 6 months after RFA. Salvage laparoscopic adrenalectomy was offered to patients who had failed RFA and remained hypertensive. Between August 2004 and August 2008, 28 patients were referred for the procedure. Radiofrequency ablation was not performed on 4 APA because of their close proximity to major vascular structures. Twenty-four patients (11 men and 13 women) with a median age of 51.5 (range = 34-63) years underwent RFA for 11 right and 13 left APA. The median tumor diameter was 16.0 (range = 4.0-25.0) mm. There was no periprocedure hypertensive crisis or major morbidity or mortality. Minor complications occurred in 4 patients (16.7%), including 1 small pneumothorax and 3 retroperitoneal hematomas (< 3 cm), which all resolved on conservative treatment. At 3 to 6 months of follow-up, CT scan showed complete tumor ablation in all patients (100%). Primary aldosteronism was biochemically resolved in 23 patients (95.8%). Salvage adrenalectomy was not performed in the single failed patient, as she remained normotensive on repeated follow-up. The overall success rate of RFA was 95.8%. Computed tomography-guided percutaneous RFA is a safe and efficacious alternative to laparoscopic adrenalectomy in treating patients with PA due to small APA.

Commentary on “Computed Tomography in the Diagnosis of Adrenal Disease” and “Nonfunctioning Adrenal Masses: Incidental Discovery on Computed Tomography”

AJR:192, March 2009 documents this watershed in the history of adrenal imaging and the starting point for modern adrenal imaging. For the first time, radiologists could see normal or minimally abnormal adrenal glands that were endo­ crinologically hyperactive. Korobkin et al. [1] showed how CT could be used in sympto­ matic patients to visualize functional adrenal masses that produced excessive cortisol, aldosterone, or catecholamines. These early images, obtained with scanning times ranging from 4.8 to 18 seconds, were primitive and laden with artifacts. Indeed, the adrenals were identified only 75% of the time, but some important and enduring observations were made by these early investigators. In patients with Cushing’s disease, func tional adrenal adenomas could be dif fer en ti ated from adrenal hyperplasia caused by adrenocortico­ tropic hormone–secreting tumors. Hyperplasia could take the form of either thickened adrenal limbs or normal­ap pearing glands. Similarly, Conn’s syndrome adenomas could be distin­ guished from adrenal hyperplasia on the basis of the presence of a small mass. Pheochromo­ cytomas were larger, hyperenhancing masses that were easily identified on CT. An ob­ servation surprising even today was that patients with Addison’s disease usually had normal­appearing ad renals rather than hypo­ plastic or atrophic glands. Korobkin et al. [1] also observed that some patients had lesions that looked just like the functional adrenal masses associated with Conn’s syndrome and Cushing’s disease but were not abnormal either clinically or bio chemically. These “incidental” lesions were considered a curios­ ity by Korobkin et al.; however, they would prove to be a harbinger of a problem to confront radiologists in the future. This pro­ blem was documented in the article by Glazer et al. [2] 3 years later. By the time of the article by Glazer et al. [2], imaging had evolved considerably. Scanning Commentary on “Computed Tomography in the Diagnosis of Adrenal Disease” and “Nonfunctioning Adrenal Masses: Incidental Discovery on Computed Tomography”