What is the recommended treatment for adrenal adenomatous lesions?

Treatment of Adrenal Adenomatous Lesions

The treatment of adrenal adenomatous lesions should be determined by their functional status and malignancy potential, with surgical resection via minimally invasive surgery recommended for all functioning adenomas and suspected malignancies. 1

Treatment Algorithm Based on Lesion Type

Functional Adenomas

1. Cortisol-secreting adenomas

   • Overt Cushing's syndrome: Unilateral adrenalectomy of the affected gland via minimally-invasive surgery (MIS) 1
   • Mild Autonomous Cortisol Secretion (MACS):
     • Consider adrenalectomy for younger patients with progressive metabolic comorbidities (diabetes, hypertension, osteoporosis)
     • If not managed surgically, annual clinical screening for worsening comorbidities 1

2. Aldosterone-secreting adenomas

   • Unilateral adrenalectomy via MIS 1
   • Preoperative preparation may include spironolactone (100-400 mg daily) 2
   • Adrenal vein sampling recommended to confirm unilateral disease before surgery 1
   • Post-operative hormonal work-up only needed short-term to confirm resolution 1

3. Pheochromocytomas

   • Unilateral adrenalectomy via MIS 1, 3
   • Requires proper preoperative alpha-blockade to prevent hypertensive crisis 3
   • Laparoscopic approach offers shorter hospital stay, decreased pain, and faster recovery 3, 4

4. Androgen/estrogen-producing adenomas

   • Surgical resection recommended 1
   • Serum testing for excess androgens should be performed when clinical signs of virilization are present 1

Non-functional Adenomas

1. Benign non-functional adenomas <4 cm

   • No further follow-up imaging or functional testing required 1

2. Benign non-functional adenomas ≥4 cm

   • Repeat imaging in 6-12 months 1
   • Consider adrenalectomy if growth >5 mm/year 1
   • No further follow-up needed if growth <3 mm/year 1

3. Indeterminate non-functional lesions

   • Management options include repeat imaging in 3-6 months versus surgical resection 1
   • Decision should be based on shared decision-making between patient and clinician 1

4. Suspected adrenocortical carcinoma (ACC)

   • Surgical resection recommended 1
   • Consider open approach for tumors >6 cm due to potential risk of peritoneal dissemination with laparoscopic approach 1

Special Considerations

Bilateral Adrenal Adenomas

• Each lesion should be characterized separately 1
• Same indications for surgery/follow-up as unilateral lesions 1
• Consider measuring serum 17-hydroxyprogesterone to exclude congenital adrenal hyperplasia 1
• Assess for adrenal insufficiency in suspected cases of bilateral infiltrative disease 1
• Partial adrenalectomy may be considered in select cases to preserve adrenal function 5

Surgical Approach

• Minimally invasive surgery (laparoscopic or robotic) is preferred when feasible 1, 6
• Open approach may be considered for:
  • Tumors >6 cm (especially if ACC is suspected) 1
  • Invasive tumors 1

Outcomes and Prognosis

• Hypertension improves or resolves in approximately:

  • 63% of patients with Cushing's syndrome
  • 56% with aldosteronoma
  • 47% with pheochromocytoma 7

• Laparoscopic adrenalectomy is associated with:

  • Low complication rates (1.2-9.7%) 7, 4
  • Short hospital stay (average 1.8 days) 7
  • No perioperative mortality in most series 7, 4

Potential Pitfalls

1. Failure to identify functional status: Always perform complete hormonal evaluation before deciding on treatment approach 1

2. Inappropriate surgical approach for suspected malignancy: Consider open approach for large tumors with malignant features to avoid peritoneal dissemination 1

3. Inadequate preoperative preparation: Pheochromocytomas require alpha-blockade; aldosterone-producing adenomas may benefit from spironolactone 2, 3

4. Missing bilateral disease: Adrenal vein sampling is crucial to confirm unilateral aldosterone production 1

5. Post-operative adrenal insufficiency: Risk increases with bilateral procedures; consider partial adrenalectomy when appropriate 5