Adrenal Nodules

 

What are the adrenal glands?

The two adrenal glands are part of the body’s endocrine system and are located just
above each kidney in the back of the upper abdomen. Although the adrenal glands are
small, they produce several hormones that affect almost every system in the body.
Hormones are substances carried through the bloodstream to many parts of the body
where they regulate various body functions. You need about one-half of one adrenal
gland for adequate hormone function.

Hormones produced by the adrenal glands include:

• Aldosterone – regulates salt balance and blood pressure
• Sex Hormones (Androgens and Estrogens) affect physical traits and sex organ
function
• Catecholamines (Epinephrine/Adrenaline, Dopamine, and norepinephrine)- affect heart rate and blood pressure, “fight or flight” response
• Cortisol – affects the immune system, metabolism, salt balance, and response to
other hormones

Why would I need my adrenal gland removed?

An adrenalectomy (adrenal gland removal) may be done if an adrenal gland contains a
tumor or if it makes and secretes too much of one or more hormones. Adrenal tumors
are usually benign (not cancerous), but rarely can be malignant (cancerous).  Occasionally, cancer can spread from another site to the adrenal gland.  Needle biopsies of the adrenal gland can be dangerous, and surgical removal for biopsy may be recommended if there is a cancer concern.

What tests are preformed to determine if I need my adrenal gland removed?

Blood and urine tests are used to diagnose conditions such as hormone over-secretion that may require adrenal
removal.

Imaging tests – including ultrasound, computed tomography (CT) scans,
magnetic resonance imaging (MRI) and radioisotope nuclear scans – 
may also be required. Sometimes a procedure to sample the hormones from each adrenal gland (adrenal vein sampling) is also needed.

Your doctor will let you know which tests are approprate and if adrenal surgery is recommended.

Do I need a biopsy prior to surgery?

Biopsy prior to surgery is usually NOT recommended and can be dangerous.  Hormone testing and imaging ARE important to diagnosis and treatment plans. Rarely, an adrenal biopsy is used
to check for spread of cancer from other places (metastatic disease).  

How do you remove an adrenal gland?

There are two surgical approaches to removing an adrenal gland: minimally invasive (laparoscopic or robotic) and open adrenalectomy.

With the a minimally-invasive approach, three or four small incisions (approximately 1/2 inch) are made in the skin on the abdomen (transabdominal approach) or on the back (retroperitoneal approach). Carbon dioxide gas is used to create space and helps your surgeon see and move instruments in your body. A laparoscope (camera) is inserted into the body which sends a video picture to a television monitor. Long surgical instruments are inserted through the other incisions to perform the procedure. One incision is typically stretched or extended at the end of the procedure to remove the adrenal gland/tumor.  Additionally, some surgeons offer “robotic adrenalectomy” which is performed similarly with the assistance of a surgical “robot”.

If you have had previous abdominal surgery, the tumor is very large, there is concern for cancer, or the surgeon feels that minimally-invasive surgery is not safe, you may need an open adrenalectomy. With the open approach, a large incision on the abdomen, side, or back is made to access the adrenal gland. In rare cases, your surgeon may start the surgery by a laparoscopic or robotic approach and convert to an open approach if there is a safety or cancer concern.

Most surgeries take about two to four hours, depending on which surgical approach is used and the experience of your surgeon.   

What are the risks and complications of an adrenalectomy?

Risks are slightly different between the right and left adrenal glands.
• Bleeding is the most common risk. It can be life-threatening and require a blood
transfusion with this surgery, especially on the right side where the adrenal gland
is connected to the inferior vena cava (the large vein that drains blood from the lower body into the heart).
• Injury to surrounding organs or structures (Right side: kidney, liver, gallbladder,
intestines; Left side: kidney, pancreas, spleen, stomach, intestines)
• Infection
• Side effects/risks from General Anesthesia
• Major hormone swings related to the underlying disease, the surgery or both.
This can affect wound healing, blood pressure fluctuations and risk for heart
attack/stroke, and other metabolic problems.
• If you have Cushing’s Syndrome (elvated cortisol) prior to surgery, you can be at risk for adrenal insufficiency (inadequate steroids/cortisol production) for months to years after surgery.  Additional steroid medications may be prescribed.  An “adrenal crisis” (severe lack of cortisol/steroids) can be severe and life-threatening. You should know signs and symptoms of adrenal insufficiency (nausea, vomiting, abdominal pain, weakness, low blood pressure, fever, confusion).  Emergency treatment usually involves additional oral or IV steroids. You may need to wear a medic-alert bracelet.

How do I prepare for surgery?

Tell your providers about all prescription and over-the-counter medications you take.
You may be prescribed additional medications to take in the days or weeks leading up to your surgery to manage the effects of excess hormones (e.g., spells, high blood pressure, low potassium level). It is important that you take the medications as instructed.  While taking these “prep” medications, people sometimes do not feel well.  Although side effects can be unpleasant, they can help us determine how well the medicines are working to block excess hormones.  If you have any questions about the medications and their side effects, talk with your provider.   Taking these medications helps prepare you for surgery and makes surgery safer.

Sometimes a special diet is recommended during testing or prior to surgery. You may also be asked to record your blood pressure, heart rate and/or blood sugars at home prior to surgery.

What does recovery look like?

Recovery depends on the type of surgery and underlying condition (pheochromocytoma
or Cushing’s, etc.). Typically, patients spend one to several days in the hospital and continue to recover for several more weeks at home prior to returning to work and usual activities. If you have Cushing’s syndrome, your recovery will likely take additional time.

What does the name of my adrenal condition mean?

Pheochromocytoma: An adrenal tumor that secretes catecholamines (a.k.a. adrenaline or epinephrine related hormones). Symptoms may include high blood pressure, fast heart rate/palpitations, anxiety, panic attacks, and pounding headaches. Patient’s often have symptomatic “spells” that last less than an hour.

Hyperaldosteronism: One or both adrenal glands produce too much aldosterone. Patients can experience severe high blood pressure that does not respond to typical medical therapy. Because microscopic tumors and bilateral adrenal overgrowth can cause excess aldosterone secretion, additional testing to identify the source of aldosterone is needed prior to planning surgery.

Treatment with medications that block aldosterone (i.e. Spironoloactone, Eplerenone) may be an alternative to surgery. “Conn’s Syndrome” or Aldosteronoma is the diagnosis given when there is a benign tumor secreting the aldosterone.

Cushing’s Syndrome: Excessive cortisol. There are many potential causes of excess cortisol, including pituitary tumors, lung tumors, adrenal tumors and certain medications. Extensive testing may be required to make the diagnosis as some patients can have “subclinical” disease where symptoms and blood testing can be within normal range or borderline. Testing can sometimes take many months and many rounds of testing. Symptoms may include: weight gain, fatigue, high blood pressure, acne, facial rounding, development of facial hair in women, easy bruising, straie (stretch marks) or “buffalo hump” (fat pad at back of neck).

Adrenalectomy may be performed to remove one or both adrenal glands depending on the source(s) of the high cortisol. After
surgery most patients require additional steroid medications that may be tapered (slowly reduced) over several months.

• Adrenal Incidentaloma:  An adrenal nodule that is found “incidentally” (accidentally) on an imaging study that was done for other reasons (for example, a chest or abdominal scan performed for another medical condition or symptom).  Incidentalomas must be checked for hormone secretion (see above) which helps determine if it should be monitored or removed.

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