What should a consult workup for an adrenalectomy consider?

Adrenalectomy Consultation Workup

A comprehensive preoperative workup for adrenalectomy should include biochemical testing for all potential hormone abnormalities, detailed imaging characterization, and specific perioperative management plans based on tumor functionality to minimize complications and optimize outcomes. 1, 2

Biochemical Evaluation

All patients with adrenal masses ≥1 cm requiring adrenalectomy should undergo complete hormonal evaluation:

• Cortisol assessment:

  • 1-mg overnight dexamethasone suppression test (mandatory for all patients) 1
  • Morning cortisol and ACTH levels 3

• Catecholamine assessment:

  • Plasma free metanephrines or 24-hour urinary fractionated metanephrines 1
  • Consider plasma methoxytyramine for malignancy risk assessment 1

• Aldosterone assessment:

  • Aldosterone-to-renin ratio for primary aldosteronism screening 1
  • Consider electrolyte panel (hypokalemia may indicate aldosteronism) 3

• Sex hormone assessment (if clinically indicated):

  • Consider evaluating for adrenal androgen or estrogen excess 4

Imaging Evaluation

• Initial imaging:

  • Non-contrast CT to determine Hounsfield Units (HU) 1
    • HU <10 indicates benign adenoma
    • HU >20 increases suspicion for malignancy

• Additional imaging for indeterminate lesions:

  • Contrast-enhanced washout CT (>60% washout at 15 minutes suggests benign lesion) 1
  • Chemical shift MRI (signal intensity loss in opposed-phase images indicates benign adenoma) 1
  • Consider FDG-PET for distinguishing potentially malignant lesions 1

• Specific imaging considerations:

  • 123I-MIBG scintigraphy for suspected pheochromocytoma (95-100% specificity) 1
  • MRI with pituitary/sellar cuts if multiple hormone abnormalities present 3

Preoperative Risk Assessment

• Cardiovascular evaluation:

  • Blood pressure control assessment and optimization
  • ECG and cardiac risk stratification, especially for pheochromocytoma 5

• Malignancy risk assessment:

  • Tumor size (>4 cm increases risk) 1, 4
  • Irregular margins or heterogeneous appearance 1
  • Poor contrast washout (<60% at 15 minutes) 1
  • Growth >5 mm/year on follow-up imaging 1

Specific Preoperative Management Based on Tumor Type

For Pheochromocytoma/Paraganglioma

• Alpha blockade (selective or non-selective) for 10-14 days before surgery 2
• Volume expansion after adequate alpha blockade 5
• Beta blockade only after adequate alpha blockade if tachycardia persists 5
• Critical: Exclude pheochromocytoma before any adrenal biopsy 1

For Cortisol-Producing Adenomas

• Plan for perioperative glucocorticoid coverage to prevent adrenal crisis 2
• For overt Cushing syndrome: Empirical perioperative glucocorticoid replacement 2
• For mild autonomous cortisol secretion: Consider postoperative day 1 morning cortisol or cosyntropin stimulation testing 2

For Aldosterone-Producing Adenomas

• Optimize potassium levels preoperatively 6
• Consider spironolactone or eplerenone preoperatively 5
• Assess duration of hypertension (duration <6 years predicts better outcomes) 6

Surgical Approach Planning

• Determine appropriate surgical approach:

  • Laparoscopic adrenalectomy (gold standard for benign lesions) 4
  • Open adrenalectomy for suspected malignancy or large tumors 4

• Consider referral to high-volume center for:

  • Suspected adrenocortical carcinoma 2
  • Complex cases requiring multidisciplinary management 2

Perioperative Complication Prevention

• Identify risk factors for complications:

  • Open approach carries higher risk than laparoscopic approach 7
  • Right-sided procedures: higher risk of bleeding 7
  • Left-sided procedures: higher risk of injury to surrounding structures (colon, pancreas, spleen) 7

• Patient education:

  • For adrenal insufficiency: Stress dosing instructions, emergency injectable steroids, medical alert identification 3

Post-Operative Follow-Up Planning

• Plan for appropriate hormonal testing post-surgery:

  • For Cushing's: Cortisol levels to assess HPA axis recovery 1
  • For pheochromocytoma: Metanephrine levels 1
  • For aldosteronism: Renin-aldosterone ratio, potassium levels 1

• Schedule appropriate imaging follow-up based on pathology findings

By systematically addressing these components in the preoperative workup, clinicians can optimize outcomes and minimize complications for patients undergoing adrenalectomy.