Internal Medicine

P1: SBT

0521779407-02 CUNY1086/Karliner 0 521 77940 7 June 7, 2007 19:18

Adrenal Tumors 73

management

General Measures

■Search for indication of primary malignancy

■Assess size of adrenal tumor

■Assessment of radiological features; irregular contour, inhomogen-

ity or necrosis, calcification, unenhanced CT with high attenuation

value (>10 HU), local invasion raise suspicion for adrenocortical car-

cinoma

■Biochemical evaluation of incidentally discovered adrenal tumors:

many functioning tumors clinically silent

What to Do First

■Exclude pheochromocytoma

■Cushingoid features: assess for cortisol excess

■Hypertension, hypokalemia, alkalosis: assess for mineralocorti-

coid/cortisol excess

■Hirsutism, menstrual irregularities: assess for androgen excess

■CT/MRI of abdomen: if <4 cm and 24-h urine 17-KS normal, not

primary adrenocortical carcinoma

■Diagnostic biopsy of the adrenal can distinguish primary vs. metas-

tastic lesion, but not benign from malignant adrenocortical neoplasm

specific therapy

■Cortisol excess: cortisol synthesis inhibitors (ketoconazole, mety-

rapone, aminoglutethimide)

■Mineralocorticoid excess: mineralocorticoid receptor antagonist

(eg, spironolactone) or potassium-sparing diuretic (eg, amiloride,

triamterene)

■Androgen excess: enzymatic inhibitors (eg, ketoconazole) or recep-

tor antagonists (eg, spironolactone)

■Pheochromocytoma: alpha-, then beta-adrenergic receptor block-

ade, catecholamine synthesis inhibitors (eg, alpha-methyl tyrosine)

■Adrenocortical carcinoma: medical management of cortisol excess,

surgical resection, radiation, adrenolytic therapy with mitotane

■Surgery indicated:

➣Pheochromocytoma

➣Unilateral functional adrenocortical adenoma

➣Tu m o r > 4 c m

➣Enlarging tumor, suspicious radiological features

➣Elevated urinary 17-KS

➣Not indicated for hyperaldosteronism from bilateral hyperplasia