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* This would provide an early and accurate evaluation of surgical success in patients with underlying Cushing’s syndrome or SCS.
* This would provide an early and accurate evaluation of surgical success in patients with underlying Cushing’s syndrome or SCS.
* Another approach would be to cover all patients with glucocorticoids perioperatively and evaluate their HPA axis at a later date (71, 74).
* Another approach would be to cover all patients with glucocorticoids perioperatively and evaluate their HPA axis at a later date (71, 74).
'''Unilateral adrenal masses''' 
===Aldosteronoma===


All patients with documented pheochromocytoma and adrenocortical cancer should undergo prompt surgical intervention because untreated pheochromocytoma may result in significant cardiovascular complications.Alpha blockade should be given before patients undergo adrenalectomy.  
==== Preoperative management ====
*The majority of patients with primary aldosteronism need to proceed with bilateral adrenal venous sampling to confirm the presence of a unilateral source for hyperaldosteronism.


Patients with adrenocortical cancer or lesions suspicious for adrenocortical cancer should also undergo prompt adrenalectomy as their disease may progress rapidly.
*Some experts recommend adrenal vein sampling in all patients with primary aldosteronism older than 40 yr due to the increased prevalence of adrenal incidentaloma in such a population (118).
 
Patients with aldosterone-producing adenomas should be offered surgery to cure aldosterone excess (
 
Some patients with documented subclinical Cushing's syndrome should be selected for surgery based upon the clinical parameters discussed above [47].
 
Adrenal masses with either suspicious imaging phenotype or size larger than 4 cm should be considered for resection because a substantial fraction will be adrenocortical carcinomas [2,14]. The clinical scenario and patient age frequently guide the management decisions in patients who have adrenal incidentalomas that fall on either side of the 4 cm diameter cutoff. As an example, most clinicians would advise resecting a uniform hypodense (9 Hounsfield unit [HU]) 3.7 cm adrenal incidentaloma in a 23-year-old woman, whereas most clinicians would choose serial imaging follow-up in an 83-year-old woman with a uniform hypodense (9 HU) 4.7 cm adrenal incidentaloma. Surgical resection should be considered in this example of a young woman because adrenal cortical nodularity is, in part, a function of aging and such a finding in a 23-year-old is not normal. In addition, the alternative would be long-term imaging follow-up, which is associated with clinically significant expense, worry, and risks. Before surgery, all patients should undergo appropriate testing for functional tumors.
 
Adrenal myelolipoma is a benign tumor composed of mature fat and interspersed hematopoietic elements that resemble bone marrow. On computed imaging, the presence of large amounts of macroscopic fat in an adrenal mass is diagnostic of a myelolipoma (image 5) [52]. Although adrenal myelolipomas may grow over time, they can usually be followed without surgical excision. However, when larger than 6 cm in diameter or when causing local mass-effect symptoms, surgical removal should be considered.
 
'''Bilateral adrenal masses''' 
 
The management of bilateral adrenal masses is different from that for unilateral masses.
 
In cases of subclinical bilateral macronodular adrenal hyperplasia (BMAH), size is not an indication for surgery, as some can be as large as 5 to 10 cm with insufficient hormone production to necessitate surgery. Patients with bilateral adrenal masses should be investigated for congenital adrenal hyperplasia [53].
 
'''Adrenalectomy''' 
 
Adrenalectomy for patients with aldosteronomas, pheochromocytoma, cortisol-secreting tumors, and adrenal incidentalomas is safe and effective [54]. An adrenalectomy may be done laparoscopically, endoscopically via the posterior approach, or as an open procedure. Laparoscopic adrenalectomy, compared with open adrenalectomy, is associated with less pain, shorter hospitalization time, less blood loss, and faster recovery [55]. The laparoscopic approach is used for most adrenal masses.
 
In patients with known or suspected adrenal carcinoma, the laparoscopic approach should only be considered if the adrenal mass is <10 cm and does not appear to be locally invasive [56,57].
 
An open adrenalectomy is recommended for all large (>10 cm) adrenal masses, including those benign imaging features, as the adrenal mass may be diagnosed as malignant on a definitive histologic review [56,58-61].


*Adrenalectomy in patients with a documented unilateral source of primary aldosteronism is more cost effective compared with lifelong medical therapy.
*Medical therapy with mineralocorticoid receptor antagonists should be reserved for those who are unable or unwilling to undergo surgery (44).
*Laparoscopic adrenalectomy compared to an open procedure is associated with a shorter hospital stay, fewer complications, and faster recovery.
*Resection of the adrenal tumor in a patient with APA will result in resolution of hypokalemia and improvement in hypertension in almost all patients.


==== Postoperative management ====
*Potassium supplementation and mineralocorticoid receptor antagonists should be stopped on postoperative day1
*Close monitoring of serum potassium.
*A temporary state of hypoaldosteronism may also develop in some patients with primary aldosteronism postoperatively.
*In the majority of cases, this condition can be managed by increasing salt intake.
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}

Revision as of 23:31, 29 August 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Overview

The mainstay of treatment for [disease name] is [therapy].

Medical Therapy

Perioperative management of patients with SCS

  • Patients with Cushing’s syndrome or SCS have adequate circulating glucocorticoids and therefore do not require glucocorticoid therapy during surgery.
  • Such patients can safely undergo surgical resection of their tumor, have their cortisol levels measured in the morning of postoperative d 1
  • be started on hydrocortisone 30 mg in the morning and 10 mg in the early afternoon until the result of the cortisol level becomes available (73).
  • This would provide an early and accurate evaluation of surgical success in patients with underlying Cushing’s syndrome or SCS.
  • Another approach would be to cover all patients with glucocorticoids perioperatively and evaluate their HPA axis at a later date (71, 74).

Aldosteronoma

Preoperative management

  • The majority of patients with primary aldosteronism need to proceed with bilateral adrenal venous sampling to confirm the presence of a unilateral source for hyperaldosteronism.
  • Some experts recommend adrenal vein sampling in all patients with primary aldosteronism older than 40 yr due to the increased prevalence of adrenal incidentaloma in such a population (118).
  • Adrenalectomy in patients with a documented unilateral source of primary aldosteronism is more cost effective compared with lifelong medical therapy.
  • Medical therapy with mineralocorticoid receptor antagonists should be reserved for those who are unable or unwilling to undergo surgery (44).
  • Laparoscopic adrenalectomy compared to an open procedure is associated with a shorter hospital stay, fewer complications, and faster recovery.
  • Resection of the adrenal tumor in a patient with APA will result in resolution of hypokalemia and improvement in hypertension in almost all patients.

Postoperative management

  • Potassium supplementation and mineralocorticoid receptor antagonists should be stopped on postoperative day1
  • Close monitoring of serum potassium.
  • A temporary state of hypoaldosteronism may also develop in some patients with primary aldosteronism postoperatively.
  • In the majority of cases, this condition can be managed by increasing salt intake.

References

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