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SU23.3 | Adrenal Tumors — SDL Guide (Part 2)
Principles of Management
Management of an adrenal tumour follows directly from the answers to the two questions, placing each patient on a grid of function and risk. A small, non-functioning, imaging-benign incidentaloma needs no surgery; it is managed by surveillance — typically interval imaging and repeat functional screening over a defined period — and discharged once stability is confirmed. A functioning tumour (a cortisol- or aldosterone-secreting adenoma, or a phaeochromocytoma) is treated by removing the source, with laparoscopic adrenalectomy the standard approach for benign functioning adenomas because it offers less pain and quicker recovery; medical optimisation always precedes surgery, and for any catecholamine-secreting tumour this means alpha-blockade before beta-blockade, while cortisol-related and bilateral resections require perioperative steroid cover. A tumour that is large or radiologically suspicious for malignancy is removed even if non-functioning, and a confirmed or strongly suspected adrenocortical carcinoma is managed by open radical adrenalectomy with complete (en-bloc) resection of the tumour without rupture of its capsule, because tumour spillage worsens the prognosis; this is followed by oncological therapy, in which the adrenolytic agent mitotane has a role, together with long-term imaging and biochemical follow-up given the high recurrence rate. An isolated adrenal metastasis may occasionally be resected in a carefully selected patient with otherwise controlled disease, but most metastatic disease is managed by treating the underlying primary. Across the whole spectrum, the principle is the same: surveillance for the small and benign, adrenalectomy (laparoscopic for benign functioning, radical for malignant) for everything that is functioning, large or suspicious — always after the right medical preparation.
CLINICAL PEARL
Before any needle goes near an adrenal mass — and before any adrenalectomy — exclude a phaeochromocytoma by measuring plasma or urinary metanephrines. Biopsying or operating on an unsuspected catecholamine-secreting tumour can trigger a life-threatening crisis. And remember that biopsy is almost never the answer for a suspected PRIMARY adrenal tumour: it rarely changes management and can seed an adrenocortical carcinoma. Reserve biopsy for confirming a suspected metastasis in a patient with a known primary elsewhere — and even then, only after phaeochromocytoma has been ruled out.
Check Your Understanding
Bring it together by placing the two patients from the hook on the function-and-risk grid. The 55-year-old man's incidentally found 3-centimetre mass is, until proven otherwise, a non-functioning benign adenoma: he still needs the full functional screen (dexamethasone suppression, metanephrines and, as he is hypertensive or not, an aldosterone:renin ratio if indicated) and an assessment of imaging characteristics, but if it is small, hormonally silent and lipid-rich on unenhanced CT, the right answer is surveillance, not surgery. The 40-year-old woman's 8-centimetre, rapidly growing mass with mixed cortisol-and-androgen excess sits firmly in the malignant corner: this is the picture of an adrenocortical carcinoma, demanding biochemical confirmation, careful imaging for local invasion and metastases, and open radical resection without capsular rupture, followed by oncological follow-up. Use these to self-test the single competency this module covers. First, can you classify any adrenal tumour by region (cortical, medullary, secondary) and by the two independent axes of functioning-versus-not and benign-versus-malignant? Second, can you describe the parallel investigation — the hormone screen for function and the size-and-imaging assessment for malignancy — and explain why biopsy is generally avoided? Third, can you state the management for each position on the grid, from surveillance of the small benign incidentaloma to radical resection of an ACC? The questions that follow check exactly these links.
SELF-CHECK
An adrenal incidentaloma is found in an asymptomatic patient. Which of the following is the correct general principle?
A. Proceed straight to image-guided biopsy to obtain a tissue diagnosis
B. Screen for hormone excess and assess malignant risk by size and imaging; biopsy is generally avoided and a phaeochromocytoma must be excluded first
C. Remove every adrenal incidentaloma regardless of size or function
D. Reassure and discharge without any investigation because the patient is asymptomatic
Reveal Answer
Answer: B. Screen for hormone excess and assess malignant risk by size and imaging; biopsy is generally avoided and a phaeochromocytoma must be excluded first
Every incidentaloma is screened for function (dexamethasone suppression, metanephrines, and aldosterone:renin ratio if hypertensive) and assessed for malignant risk by size and imaging characteristics. Biopsy is generally avoided for a suspected primary adrenal tumour, and a phaeochromocytoma must always be excluded before any intervention. Neither blanket removal nor discharge-without-work-up is correct.