Indications for Adrenalectomy in Elderly Females
Adrenalectomy in elderly females is indicated for specific functional adrenal tumors and suspected malignancies, with the decision based on the type of lesion rather than age alone, as surgical outcomes in patients ≥70 years are comparable to younger patients. 1, 2
Primary Indications for Surgery
Functional Adrenal Lesions (Absolute Indications)
Pheochromocytoma must be surgically resected regardless of age, with alpha-blocker therapy required 1-3 weeks preoperatively to prevent intraoperative catecholamine surge. 1 Minimally invasive surgery should be performed when feasible. 1
Aldosterone-producing adenomas warrant laparoscopic adrenalectomy after confirmation by adrenal venous sampling (AVS), which improves blood pressure in virtually 100% of patients and achieves complete hypertension cure in approximately 38-50% of cases. 1, 3 This is particularly relevant for elderly females with resistant hypertension and/or unprovoked hypokalemia. 1
Clinically apparent Cushing's syndrome from unilateral cortisol-secreting adenomas requires unilateral adrenalectomy of the affected gland, with minimally invasive surgery preferred when feasible. 1
Mild Autonomous Cortisol Secretion (MACS)
For elderly patients with MACS (previously called subclinical Cushing's), the decision is more nuanced. Adrenalectomy can be considered for select patients with progressive metabolic comorbidities (hypertension, diabetes, cardiovascular events, vertebral fractures) attributable to cortisol excess, though this recommendation is weaker for elderly patients. 1 The guidelines specifically note that quality of life and medical comorbidities should be considered when managing elderly patients with adrenal masses. 1
Suspected Malignancy
Any mass with obvious signs of malignancy on CT (large size >4 cm, heterogeneity, invasion, or necrosis) should be surgically resected if the patient is healthy enough for surgery. 1 For suspected adrenocortical carcinoma (ACC):
- Masses >5-6 cm consistent with ACC should be approached via open surgery rather than laparoscopically to reduce peritoneal dissemination risk. 1
- Laparoscopic/robotic adrenalectomy is appropriate for smaller, more contained masses. 1
Age-Specific Considerations for Elderly Females
Age alone should not preclude surgery in elderly patients. Recent data demonstrates that patients ≥70 years undergoing adrenalectomy have similar serious complication rates (9.1% vs 6.5%), overall complication rates (44.2% vs 40.3%), hospital stays, and mortality compared to younger patients. 2 However, elderly patients experience more cardiovascular complications (27.0% vs 6.7%), requiring careful preoperative cardiac risk assessment. 2
The Goldman multifactorial cardiac risk scheme reliably predicts postoperative outcomes in elderly patients, with Goldman class II or greater predicting increased morbidity and mortality. 4 Operative mortality for functional tumors (pheochromocytoma, primary aldosteronism) is essentially zero, while adrenocortical carcinoma carries significantly higher operative mortality (43%). 4
Lesions NOT Requiring Surgery
Benign non-functional adenomas <4 cm with benign imaging characteristics (<10 HU) do not require surgery or further follow-up. 1 This includes myelolipomas and other small masses containing macroscopic fat. 1
For non-functional lesions ≥4 cm that appear radiologically benign, repeat imaging in 6-12 months is recommended, with adrenalectomy considered only if growth exceeds 5 mm/year after repeating functional workup. 1
Key Clinical Pitfalls
Never perform adrenalectomy for aldosterone-producing adenomas without AVS confirmation, as 25% of patients would undergo unnecessary surgery based on CT imaging alone due to non-functioning adenomas and nodular hyperplasia. 1
Always exclude pheochromocytoma before any adrenal surgery, even if the mass appears to be metastatic disease, as unrecognized pheochromocytoma causes catastrophic intraoperative complications. 1
Bilateral adrenalectomy for asymptomatic cortisol-secreting adenomas should be avoided due to resulting adrenal insufficiency. 1