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Neoplasm of adrenal gland — Clinical Guidelines

Overview

Adrenal neoplasms encompass a spectrum of benign and malignant tumors arising from the adrenal cortex or medulla, including adenomas, carcinomas, and rare entities like myelolipomas and leiomyosarcomas. Diagnosis and management require multidisciplinary collaboration among endocrinologists, surgeons, and radiologists 2.

Diagnosis

Imaging: CT and MRI are essential for characterizing adrenal masses, distinguishing between benign and malignant lesions based on size, density, and enhancement patterns 2 5 17 18.

Functional Testing: Hormone assays (e.g., cortisol, aldosterone, metanephrines) are crucial for identifying functional adrenal tumors 2.

Biopsy: Fine-needle aspiration may be considered preoperatively to avoid unnecessary surgery, particularly for large myelolipomas 11 14.

Pathological Evaluation: Surgical pathology reports should adhere to standardized recommendations for accurate classification of adrenal tumors 6 7.

Management

Surgical: Adrenalectomy (open, laparoscopic, retroperitoneal) is the mainstay for both benign and malignant tumors, with laparoscopic approaches favored for benign lesions 5 10.

Benign Tumors: Observation may be appropriate for small, non-functional adenomas 2.

Malignant Tumors: Aggressive surgical resection followed by adjuvant therapy (e.g., chemotherapy, radiation) based on histology and stage 1 3.

Myelolipomas: Surgical excision is recommended for symptomatic or large lesions to prevent complications like retroperitoneal hematoma 11 20.

Special Populations

Pediatrics: Neonatal adrenal masses can include adrenal cortical carcinoma and neuroblastoma, requiring prompt evaluation and management 16.

Elderly: Surgeon volume and experience may influence outcomes, with high-volume surgeons potentially offering better results 1.

Comorbidities: Management should consider patient-specific comorbidities and surgical risk stratification 1.

Key Recommendations

Utilize CT and MRI for accurate characterization of adrenal masses (Evidence: Moderate 2 17 18).

Perform adrenalectomy via laparoscopic approaches when feasible for benign tumors to minimize morbidity (Evidence: Moderate 5 10).

Adhere to standardized surgical pathology reporting guidelines for adrenal tumors to ensure accurate diagnosis and classification (Evidence: Expert opinion 6 7).

Consider functional testing to identify hormone-producing adrenal neoplasms (Evidence: Moderate 2).

Surgical resection is essential for symptomatic or large myelolipomas to prevent complications (Evidence: Moderate 11 20).

References

1 Yong C, Kim A, Slaven JE, Boris RS, Sundaram CP. Case Volume Is Not Associated With Outcomes After Adrenalectomy Performed by Urologic Surgeons. Urology practice 2024. link 2 Mazzaglia PJ, Varghese J, Habra MA. Evaluation and management of adrenal neoplasms: endocrinologist and endocrine surgeon perspectives. Abdominal radiology (New York) 2020. link 3 Doppalapudi SK, Shah T, Fitzhugh VA, Bargman V. Primary adrenal leiomyosarcoma with inferior vena cava extension in a 70-year-old man. BMJ case reports 2019. link 4 Hansel DE, Reuter VE. Adrenal Pathology in the Adult: A Urological Pathologist's Perspective. Advances in anatomic pathology 2016. link 5 Sung GT, Hsu TH, Gill IS. Retroperitoneoscopic adrenalectomy: lateral approach. Journal of endourology 2001. link 6 . Recommendations for reporting of tumors of the adrenal cortex and medulla. Association of Directors of Anatomic and Surgical Pathology. Human pathology 1999. link90240-x) 7 Lack EE. Recommendations for the reporting of tumors of the adrenal cortex and medulla. Association of Directors of Anatomic and Surgical Pathology. Virchows Archiv : an international journal of pathology 1999. link 8 Cyran KM, Kenney PJ, Memel DS, Yacoub I. Adrenal myelolipoma. AJR. American journal of roentgenology 1996. link 9 Bal MS, Kataria AS, Kahlon SK, Kahlon SS. Myelolipoma of adrenal gland in association with occult malignancy--a case report. Indian journal of pathology & microbiology 1996. link 10 Kelly M, Jorgensen J, Magarey C, Delbridge L. Extraperitoneal 'laparoscopic' adrenalectomy. The Australian and New Zealand journal of surgery 1994. link 11 Vierna J, Laforga JB. Giant adrenal myelolipoma. Report of a case and review of the literature. Scandinavian journal of urology and nephrology 1994. link 12 Perimenis P, Giannoulis S, Tzanakakis G, Asimakopoulou V, Melekos M, Barbalias G. Myelolipoma of the adrenal gland. Urologia internationalis 1993. link 13 Meaglia JP, Schmidt JD. Natural history of an adrenal myelolipoma. The Journal of urology 1992. link37482-7) 14 Rao M. Adrenal myelolipoma. Australasian radiology 1992. link 15 Bosco PJ, Silverman ML, Zinman LM. Primary angiosarcoma of adrenal gland presenting as paraneoplastic syndrome: case report. The Journal of urology 1991. link38012-6) 16 Butler H, Bick R, Morrison S. Unsuspected adrenal masses in the neonate: adrenal cortical carcinoma and neuroblastoma. A report of two cases. Pediatric radiology 1988. link 17 Cintron E, Quintero EC, Perez MR, Ramirez-de Arellano GA, Manich BV. Computed tomography, sonographic, and radiographic findings in adrenal myelolipoma. Urology 1984. link90085-2) 18 Tsukaguchi I, Sato K, Ohara S, Kadowaki T, Shin T, Kotoh K. Adrenal myelolipoma: report of a case with CT and angiographic evaluation. Urologic radiology 1983. link 19 Selli C, Carini M, Rosi P, Carcangiu ML. Adrenal myelolipoma. The Italian journal of surgical sciences 1983. link 20 Ishikawa H, Tachibana M, Hata M, Tazaki H, Akatsuka S, Iri H. Myelolipoma of the adrenal gland. The Journal of urology 1981. link54745-x) 21 Weiner SN, Bernstein RG, Lowy S, Karp H. Case report. Combined adrenal adenoma and myelolipoma. Journal of computer assisted tomography 1981. link 22 Vargas AD. Adrenal hemangioma. Urology 1980. link90145-4) 23 Fink DW, Wurtzebach LR. Symptomatic myelolipoma of the adrenal: report of a case with computed tomographic evaluation. Radiology 1980. link 24 Nicholls K. Massive adrenal haemorrhage complicating adrenal neoplasm. The Medical journal of Australia 1979. link

Neoplasm of adrenal gland