What criteria should be used to determine if an adrenalectomy is necessary for an elderly female patient?

Determining the Need for Adrenalectomy in Elderly Female Patients

The decision to remove an adrenal gland in an elderly female patient depends primarily on whether the mass is functional (hormone-secreting), shows imaging features of malignancy, or demonstrates growth on surveillance—with quality of life and medical comorbidities being critical considerations in this population. 1

Initial Functional Assessment

All elderly patients with adrenal masses require comprehensive hormonal screening before any surgical decision, regardless of symptoms:

• Screen for autonomous cortisol secretion using 1 mg dexamethasone suppression test, measuring serum cortisol the following morning 1. Cortisol >138 nmol/L (>5.0 mg/dL) indicates autonomous secretion, 51-138 nmol/L (1.9-5.0 mg/dL) suggests possible secretion requiring additional testing, and <50 nmol/L (<1.8 mg/dL) excludes it 1

• Screen for pheochromocytoma with plasma or 24-hour urinary metanephrines if the mass shows >10 HU on non-contrast CT or if the patient has signs of catecholamine excess (hypertension, headaches, palpitations, sweating) 1

• Screen for primary aldosteronism with aldosterone-to-renin ratio in patients with hypertension and/or hypokalemia 1. A ratio >30 with elevated aldosterone and suppressed renin indicates hyperaldosteronism 1

• Screen for excess androgens only if clinical virilization is present or adrenocortical carcinoma is suspected 1

Absolute Indications for Adrenalectomy

Functional Tumors (Regardless of Size)

Pheochromocytoma must be resected in all cases, as uncontrolled catecholamine excess during any surgical procedure can cause fatal cardiovascular events 1, 2. Alpha blockade for 1-3 weeks preoperatively is mandatory 1

Aldosterone-secreting adenomas require laparoscopic adrenalectomy after confirmation with adrenal vein sampling to lateralize production 1. Medical management with mineralocorticoid receptor antagonists is reserved only for bilateral hyperplasia or nonsurgical candidates 1

Clinically apparent Cushing's syndrome (cortisol >138 nmol/L with symptoms like proximal muscle weakness, purple striae, buffalo hump, severe hypertension) mandates unilateral adrenalectomy of the affected gland 1. The hypercortisolism causes severe metabolic derangements including hypertension, hyperglycemia, immunosuppression, and impaired wound healing that increase surgical morbidity and mortality 3

Malignancy or Suspected Malignancy

Any mass with obvious malignancy features on CT requires surgical resection 1. Malignancy features include:

• Size >4 cm with concerning characteristics 1
• Heterogeneity, irregular margins, or evidence of invasion/necrosis 1

• 10 HU on unenhanced CT (lipid-poor) 1

• Poor washout on contrast-enhanced CT 1

Laparoscopic/robotic adrenalectomy is preferred for smaller, contained masses that can be resected without rupturing the tumor capsule 1. Open adrenalectomy is indicated for larger adrenocortical carcinomas, locally advanced tumors, lymph node metastases, or tumor thrombus 1

Relative Indications Requiring Shared Decision-Making

Mild Autonomous Cortisol Secretion (MACS)

Younger elderly patients with MACS (cortisol 51-138 nmol/L) and progressive metabolic comorbidities attributable to cortisol excess can be considered for adrenalectomy after shared decision-making 1. Key considerations include:

• Presence of hypertension, type 2 diabetes, or asymptomatic vertebral fractures that are worsening 1
• Patient's overall health status and physiologic reserve 1
• Patients not managed surgically require annual clinical screening for new or worsening comorbidities 1

Large Benign-Appearing Masses

Non-functional adrenal lesions that are radiologically benign (<10 HU) but ≥4 cm should undergo repeat imaging in 6-12 months 1. Adrenalectomy should be considered if:

• Growth >5 mm/year after repeating functional workup 1
• Patient preference after discussing risks versus surveillance 1

Special Considerations for Elderly Patients

Quality of life and medical comorbidities must be carefully weighed when considering adrenalectomy in elderly patients 1. The Goldman multifactorial cardiac risk scheme reliably predicts postoperative outcomes in this population 4

Age alone is not a contraindication to laparoscopic adrenalectomy, which offers low morbidity, fast recovery, and short hospital stays even in patients aged 65-84 years 5. Historical data show:

• Operative mortality of 7% overall in elderly patients, but 0% for pheochromocytoma and primary hyperaldosteronism 4
• Significantly higher mortality (43%) for adrenocortical carcinoma 4
• Goldman class II or greater predicts increased morbidity and mortality 4

Laparoscopic approach is preferred when feasible as it reduces complications and promotes faster recovery 1, 5. Conversion to open surgery occurs in approximately 3-11% of cases 5, 6

Masses That Do NOT Require Surgery

Benign non-functional adenomas <4 cm, myelolipomas, and other small masses containing macroscopic fat do not require further follow-up imaging or functional testing 1

Indeterminate non-functional lesions require either repeat imaging in 3-6 months or surgical resection based on shared decision-making 1

Critical Pitfalls to Avoid

Never proceed with any elective surgery in patients with undiagnosed or untreated functional adrenal pathology, as this can lead to life-threatening complications including cardiovascular collapse (pheochromocytoma) or metabolic crises (Cushing's syndrome) 3

Always exclude pheochromocytoma before adrenal biopsy, as biopsy of unsuspected pheochromocytoma can trigger hypertensive crisis 1

Adrenal biopsy has limited clinical value and should not be part of initial workup except when metastatic disease from extra-adrenal malignancy would change management, and only after excluding pheochromocytoma 1

Following bilateral adrenalectomy, lifelong glucocorticoid and mineralocorticoid replacement is mandatory with regular pituitary MRI monitoring to detect Nelson syndrome 3, 7, 8. Patients require counseling about permanent hormone replacement and risk of adrenal crisis before surgery 9

Chronic fatigue affects 60% of bilateral adrenalectomy survivors, and an active program of long-term rehabilitation is essential 8