Adrenal Metastases:

Most common cancer metastasizing to the adrenals:
- Lung ca
- RCC
- melanoma
- breast ca
- gastrointestinal ca
- HCC
- lymphoma

Work-up:
- patients with a solitary adrenal mass and symptoms suggestive of malignancy should have screening colonoscopy, mammography and CXR to try and identify the primary tumor
- PET scan may be helpful to identify the primary disease
- FNA can be performed: but only after a pheo has been ruled out

Presence of a solitary met - may benefit from adrenalectomy
- usually small and contained within capsule.
- lap adrenalectomy has been shown to have an equally effective outcome as open adrenalectomy
- 5 year survival 25%

Virilizing and Feminizing Adrenal Tumors

- Rare
- usually symptomatic

>80% are malignant
- almost all feminizing tumors malignant
- 50% of virilizing tumors are malignant

- because they are so rare, testing for sex hormone excess during work-up of incidentaloma should only be done if there are clinical signs of virilization or feminization

Diagnosis:
- Virilizing tumors: serum testosterone, serum dihydroepiandrostenedione, 24 hr urine 7-hydroxysteroid, 24 hr urine 7-ketosteroids (serum androgens and 24 hr urine keto-steroids suppressed if ovarian cause)
- dexamethasone suppression test can differentiate between adrenal and ovarian cause
- Feminizing tumor: serum estrogen and suppressed FSH, LH and gonadotropins confirm feminizing adrenal tumor (as opposed to testicular tumor)
- CT scan can generally localize a tumor

Consider that most are malignant when deciding if going to attempt laparoscopically

Adrenal Cushing's syndrome

Cushing's syndrome: caused by glucocorticoid excess
- central obesity, hypertension, moon facies, easy brusibility, weakness, depression, polyuria, glucose intolerance and diabetes

Gluccocorticoid secreting lesiosn:
- adrenal: adenomas, hyperplasia, adrenocortical carcinomas
- pituitary: adenomas, hyperplasia
- ectopic: SCLLC, bronchial carcinoid tumors, thymomas, pancreatic islet cell tumors

Diagnosis:

- elevated 24-hour urinary free cortisol most sensitive and specific test

- if 24 hour urine is negative formal low-dose dexamethasone suppression test can be performed

Important distinction during work-up:
- ACTH dependent or independent (adrenal adenoma and candidate for resection)
- measure plasma ACTH levels: should be low in ACTH independent tumors
Imaging:
- CT or MRI both can be used for localizing the tumor
- if pituitary or ectopic lesion suspected then imaging of head/chest may be warranted

Pre-op considerations:
- treat with stress-dose of steroids: taper slowly (the contralateral adrenal will be suppressed from pre-operative excess steroid secretion)
- pre-op antibiotics (due to immunosuppression from steroids)

TReatment:
- surgical resection of bilateral hyperplasia is indicated in this disease
- patient will requirer lifetime glucocorticoid and mineralocorticoid replacement (Florinef 0.1mg qD)

Aldosteronoma

Classic triad of Conn's syndrome:
- Hypertension
- Hypokalemia
- Polyuria

Diagnostic test is PAC:PRA >30
- PAC: plasma aldosterone concentration
- PRA: plasma renin activity
- second confirmatory test is an aldosterone stimulation test (positive if urinary aldosterone level elevated during a saline infusion)

Workup: adenoma vs. hyperplasia
- important step in working patient with suspected aldosteronoma is to determine if you are dealing with a unilateral adrenocortical adenoma (2/3 of patients) or bilateral hyperplasia
- other very rare causes include adrenocortical carcinoma, angiotensin II responsive adenomas, familial hyperaldosteronism type I and type II
- this can be done by imaging - CT scan may show a solitary lesion

Indications for selective adrenal vein catheterization:
- sampling of adrenal vein may be necessary to localize adenoma.  placement of catheter confirmed by increase in cortisol concentration as compared to IVC
- looking for ~5 fold increase in aldosterone compared to the other side
- indicated with there is adrenal hypertrophy, bilateral nodules, no lesions

Pre-operative considerations:
- patient begins spironolactone pre-operatively to control hypertension and normalize potassium levels.
- other antihypertensives are added as needed
- stop spironolactone immediately post-op