What is the diagnosis and treatment for an adrenal adenoma?

From the Guidelines

Adrenal adenomas should be managed based on their functional status and size, with functioning adenomas producing excess hormones like cortisol, aldosterone, or catecholamines typically requiring surgical removal via laparoscopic adrenalectomy, as recommended by the most recent guidelines 1.

Management of Adrenal Adenomas

The management of adrenal adenomas depends on whether the adenoma is functioning or non-functioning. For non-functioning adenomas smaller than 4 cm with benign imaging characteristics, observation with follow-up imaging at 6-12 months is typically recommended.

• Non-functioning adenomas smaller than 4 cm with benign imaging characteristics: observation with follow-up imaging at 6-12 months
• Functioning adenomas producing excess hormones: surgical removal via laparoscopic adrenalectomy
• Adenomas larger than 4 cm or with suspicious imaging features: surgical removal due to the small risk of malignancy

Surgical Removal

Surgical removal via laparoscopic adrenalectomy is usually indicated for functioning adenomas producing excess hormones like cortisol (Cushing's syndrome), aldosterone (Conn's syndrome), or catecholamines.

• Patients with cortisol-producing adenomas may need perioperative steroid coverage (hydrocortisone 100 mg IV followed by a taper) to prevent adrenal insufficiency after surgery
• For aldosterone-producing adenomas, medical management with spironolactone (25-100 mg daily) or eplerenone (25-50 mg daily) may be used before surgery or in patients who cannot undergo surgery

Postoperative Care

After removal of functioning adenomas, patients should be monitored for resolution of hormonal excess and potential adrenal insufficiency.

• Postoperative corticosteroid supplementation is required until recovery of the hypothalamus-pituitary-adrenal (HPA) axis, as noted in the guidelines 1
• The prevalence of adrenal adenomas increases with age, affecting approximately 3-7% of adults, with most being non-functioning and requiring only periodic surveillance, as supported by the evidence 1

From the Research

Adrenal Adenoma Overview

• Adrenal adenomas are hormone-secreting tumors that can cause various health issues, including Cushing's syndrome, Conn's syndrome, and pheochromocytomas 2
• These tumors can be functional or non-functional, and their treatment often involves surgical removal 2, 3, 4

Surgical Indications and Techniques

• Indications for adrenalectomy include malignancy suspicion or malignant tumors, non-functional tumors with the risk of malignancy, and functional adrenal tumors 2
• Laparoscopic adrenalectomy is the gold standard treatment for selected patients, and it can be performed transperitoneally or retroperitoneoscopically 2, 5
• Open surgery is indicated in cases of malignancy or suspected malignancy and large tumors when laparoscopic surgery is contraindicated 2

Laparoscopic Partial Adrenalectomy

• Laparoscopic partial adrenalectomy is a minimally invasive procedure with a low complication rate, and it provides the benefit of retaining functional tissue on the side of the affected adrenal gland 3
• This procedure is recommended for patients with small, potentially benign tumors of the adrenal gland, even with a healthy contralateral adrenal gland 3
• However, the risk-to-benefit ratio must be carefully weighed against the potential advantage of partial adrenalectomy, especially in cases with multiple adrenal space-occupying lesions 6

Comparison of Surgical Techniques

• A study comparing laparoscopic partial and total adrenalectomy for aldosterone-producing adenoma found that total adrenalectomy resulted in better outcomes, with all patients showing recovery from hypertension and suppressed plasma renin activity 6
• Another study comparing retroperitoneoscopic adrenalectomy via a single large port (RASLP) and conventional laparoscopic adrenalectomy (CLA) found that CLA resulted in decreased operative times, blood loss, and postoperative complications 5