B10. Surgical treatment of adrenal tumors

Page created on October 14, 2021. Not updated since.


For introduction, types, and pathology of adrenal tumours, see the corresponding pathology 2 topic.


Incidentalomas are incidentally discovered asymptomatic tumours of the adrenal gland. In most cases they’re adrenal adenomas. They’re found on 0,3 – 5% of abdominal CT scans and are therefore quite common.

These tumours may grow or become malignant, and they may worsen other endocrine diseases like diabetes, osteoporosis, or hypertension. For these reasons, the patient must be evaluated for the likelihood for it being malignant and whether it’s hormonally active (Cushing syndrome, phaeochromocytoma, aldosteronoma).

Certain CT characteristics increase the risk of the tumour being malignant. Benign findings include small size, smooth border, rapid contrast washout. Malignant findings include irregular shape, inhomogeneous density, and delayed contrast washout.

If phaeochromocytoma is suspected, 24-hour urinary metanephrines should be measured. All patients should undergo dexamethasone suppression test to detect subclinical Cushing syndrome.

Surgery is indicated if investigations show phaeochromocytoma, subclinical Cushing syndrome

Preoperative management

Imaging, hormonal screening, and biopsy are important parts of preoperative management.

Surgical treatment of adrenal tumours

Adrenal surgery is mostly performed laparoscopically. Large tumours (> 10 cm, mostly cancers) may be operated in an open fashion instead.

Laparoscopic adrenalectomy is indicated for:

  • Cushing syndrome caused by adrenal tumour
  • Conn syndrome
  • Phaeochromocytoma
  • Angiomyolipoma
  • Incidentaloma
  • Adrenal metastasis

Before surgical treatment of phaeochromocytoma, the patient should receive alpha blocker followed by beta blocker, to prevent hypertensive crisis due to surgical manipulation of the tumour. Surgical removal of phaeochromocytoma involves the “no-touch” technique to minimise the risk of catecholamine-release-induced hypertensive crisis intraoperatively.

Contraindications to laparoscopy:

  • Large tumours (> 10 cm)
  • Cortical carcinoma
  • Malignant phaeochromocytoma

Enucleation refers to removal of the mass while leaving the rest of the gland intact. This is used for bilateral tumours or unilateral tumours with massive hormone production.

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