Incidentally Detected Adrenal Mass: A Clinical Approach

Welcome to MedPod, the audio podcast on topics of medicine from the Department of Internal Medicine at AFMC. Today, we broach on a topic which is more specialized when it comes to topics in endocrinology and today we shall be discussing an approach to adrenal masses. With advent of various imaging modalities, it often happens that while imaging a patient for some other condition, we often find patient to be having some adrenal mass and the patient is referred for endocrinology or medicine consult and that is where the student and the physicians need to know how to approach. To discuss this very important topic, we have with us the Nareesh Bansal, head of the department endocrinology at Command Hospital, Southern Command, senior endocrinologist, very ardent academician and an excellent teacher, Nareesh happens to be a clinical tutor from this department and now he is heading the department in the hospital across. So welcome Nareesh. Thank you sir, it is an honor to be here. So we shall be discussing this topic and I want you to simplify it for our students. So why and what are the situations where these masses are usually incidentally detected? As the name goes, these masses, number of times these masses are incidentally detected. For example, if the patient is being evaluated for pain abdomen, gets ultrasound or CT abdomen done for pain abdomen and is incidentally found to have an adrenal mass. Number of times these patients come to us that we were being evaluated for pain abdomen, nothing has been found on pain abdomen but incidentally we had no symptoms and adrenal mass has been discovered. So there is a lot of anxiety among the patient that such a mass has been discovered incidentally. So in literature if you look at it, how common are these masses? Actually if we go by the statistics, incidental adrenal masses are quite common. If we go by the autopsy studies, they are seen in about 30% of all the topsy patients, these incidental masses and if we go by the age up till 40 years, 1% of the population will have one of the other adrenal mass and it increases to about 7 to 10% by about 70 years of age. So incidental masses are very, very common, whether they are functional or non-functional, these incidental masses may be discovered incidentally while the patient is being evaluated for some other problem. So any mass anywhere the patient always gets worried. So usually when you see in practice these patients, what are their usual concerns and more than patients concerned as a physician, what shall we be looking for when we find an adrenal mass? When these patients come with the report of an adrenal mass, first of all we have to check whether they were, their features suggestive of some adrenal disease and because of that adrenal disease, these adrenal masses are present. And then we have to allay the patient's anxiety, the patient's anxiety is because are these masses required to be operated? So we have to allay all these anxieties which the patient comes with, we have to see whether the adrenal mass is functional or it is a non-functional mass, whether it is a benign or a malignant mass, and whether the patient has associated hypertension or not, these are the main concerns which we are supposed to address when the patient comes with adrenal mass. Right, so basically patients always feel scared that it could be a cancer because that is the commonest correlation they have with any mass in the body. And for a physician I think we are concerned whether it is functional or not and can it be medically managed or does it require removal? So to ascertain all this, how do we go about taking history and examining patients to reach that conclusion? This is a very important thing because if an adrenal mass has been discovered we have to first find out whether the patient is having any symptoms which may also present with an adrenal mass, symptoms suggest symptoms which this adrenal mass may cause, symptoms suggestive of excess hormone secretion or hormone deficiency. So in excess hormone secretion we have to look for features of Cushing syndrome, we have to look for features of pheochromocytoma, we have to ask the histories which may be suggestive of a pheochromocytoma or we have to see whether the patient is having hypertension or not. So these are the very important symptoms, in history we have to especially ask the patient whether there is any easy bruising, whether there is proximal myopathy which is present, whether there is any reddish color stria which may be present over the body or there is uncontrolled previously the patient was very well controlled on diabetes and hypertensive medicines but of late the patient has the diabetes and hypertension has become uncontrolled. These are some of the subtle symptoms which may be present even if the hormone secretion is very less. So we have to look for all these symptoms whenever the patients come with an adrenal mass. Besides that the adrenal masses may also present with the features suggestive of adrenal insufficiency or some infection in that adrenal mass. So we have to look for telltale signs of infection anywhere in the body especially tuberculosis. So we have to be very careful and look for all the features of pulmonary or extra pulmonary tuberculosis anywhere in the body which may also present with an adrenal mass besides that any features of malignancy anywhere in the body that has also to be looked for any features of weight loss, fever or any other B symptoms which the patient may present with and now also having an adrenal mass. So basically looking at adrenal as a gland which predominantly has 3 main adrenal cortical hormone axis which can over function. So in that case we are looking for glucocorticoid or medrallocorticoid axis like you mentioned and also at times in malignancies we may find some adhesion axis as well and of course the adrenal medulla which can present with features of piochromocytoma which classically may present with those peroxisin but often we find these patients just coming with sustained hypertension. Now what are the investigations that you require because most of the time after having clinically seen this patient may not have much of clinical findings also but it is important to select investigate them for all these features. As I told all the adrenal masses has to be accessed for functional or the non-functional status as far as the functional status is concerned we are required to first check for the blood pressure on examination if the blood pressure is high then certain investigations are required to be done but all adrenal masses should undergo evaluation for Cushing syndrome that is cortisol excess, glucocorticoid excess as well as for piochromocytoma. Any patient presenting with adrenal mass has to be evaluated for features of glucocorticoid excess or catecholamine excess. However if the patient also has hypertension on examination especially if the hypertension is uncontrolled requiring number of drugs to control the hypertension then it becomes very important to check for the mineralocorticoid excess also that is plasma and testron and renin concentration also during the evaluation of this adrenal mass. So these are the biochemical investigations to look for Cushing syndrome, to look for con syndrome and to look for piochromocytoma in the patient who presents with an adrenal mass. Right. So in this how does imaging help? Is it should it follow the biochemical evaluation or should it be done before the biochemical evaluation? There is a victim in endocrinology that no imaging has to be done before the disease has been picked up biochemically, confirmed biochemically because number of endocrine glands may have incidental masses which may be present which are not of much concern. So imaging should not proceed should not at all proceed the biochemical investigations. We have to do the biochemical investigations first prove the excess or deficiency and thereafter proceed with imaging. However in this case when the patient may present with incidental adrenal masses which has been discovered for some other when the imaging was done for some other reason then we go backward do the biochemical evaluation and prove that whether it is a functional or a non-functional mass. And at times you may have a person patient coming with an ultrasound finding so in such situation we may do a better imaging modality like a CT scan. Yes the CT is very important investigation as far as adrenals are concerned because the CT may give us very important findings to see that whether it is benign tumor or it is a malignant tumor. This is one of the main concerns of the patient is it a cancer. So CT can give us lot of clues whether it is a benign mass or it is a malignant mass. In non-contrast CT also if the initially if the distance CT it may show a very less household unit so probably if it is less than 10 probably we can think that it is probably a benign mass but if it is more than 10 we have to think in terms of evaluating this mass whether this is a malignant mass. Besides that the CT will also tell us whether it is a well defined tumor, what is the vascularity of the tumor, what is the calcification whether it is heterogenicity in this tumor because that may indicate towards the pheochromocytoma or a malignant tumor rather than a benign tumor. In all benign tumor the household unit is less than minus 10 so if it is less than minus 10 it is a lipid rich adenoma we are rest assured that we are dealing with the probably a benign tumor. Besides that during the CT in a contrast CT we can also look for absolute washout and the relative washout. If the absolute washout is more than 60 percent and the relative washout is more than 40 percent that means we are probably dealing with the benign tumor. The malignant tumors have a very less washout absolute washout will be less than 50 percent. So the CT can give us a lot of information whether it is a benign or it is a malignant tumor. Right. So like you rightly mentioned biochemical confirmation is most important in all these conditions. So and also it is important that the samples are collected properly because pre analytical errors are well known in endocrine sampling. So how are samples required to be collected when you are evaluating adrenal mass? So whenever we are evaluating an adrenal mass we have to rule out the Cushing syndrome. We have to rule out as I already told we have to rule out the fiochromocytoma and if the patient is hypertension we have to rule out the mineralocorticoid. So as far as Cushing syndrome is concerned first of all we take a basal sample at 0800 yards. This is this basal sample is just required to rule out any exogenous steroid intake. If the basal cortisol is found to be high then we proceed with the other test that is the overnight dexamethasone suppression test in which we give 1 milligram of dexamethasone at 11 p.m. in the night and next morning we collect the cortisol sample. If the cortisol serum cortisol after overnight dexamethasone suppression is less than 1.8 microgram per deciliter then it is probably a non-secreting non-cortisol secreting tumor. We need not proceed further as far as the investigations for Cushing syndrome is concerned. So overnight dexamethasone suppression test will tell us whether it is a cortisol secreting tumor and if it is more than 1.8 microgram per deciliter then we proceed with the other test for autonomous cortisol secretion. The second test which we do is the plasma metanephanes or the 24 hour urinary metanephanes and non-metanephanes. Now this is a very important test. When we are collecting the plasma metanephanes and non-metanephanes samples we have to see that the patient is not taking any caffeinated beverages. The patient is not on any drugs, sympathomimetics, patient is not on any allergic medicines, patient is not on any decongestant. We have to first see that patient is not on these medicines. Then the patient, if we once we are sure that the patient is not taking all these medicines then we make the patient early morning, we make the patient rest for about 10 minutes and thereafter collect the plasma metanephanes and non-metanephanes. As far as urinary metanephanes, non-metanephanes are concerned we require a 24 hour urinary sample and this 24 hour urinary sample there is no preservatives required, but if the sample can be tested early. However, if the sample has to be transported somewhere then it has to be stored with sodium metamethylpite. Regarding the collection of the sample of metanephanes, plasma metanephanes and non-metanephanes, it has to be done in a hyperanised tube and it has to be cold preserved. Now regarding the sample for if the patient also has hypertension then we have to check for the mineralocorticoide axis also. In that case, we have to do the plasma aldosterone and plasma renin activity. Plasma renin activity is a very difficult test to do it, not routinely available. So, in place of that we what we do is the direct renin levels. In case of direct renin and plasma aldosterone, we make the patient work for about 1 to 2 hours. This is to make the patient stimulate his volume status and the renin levels and then the patient is made to lie down for about 10 minutes and then collect the samples for plasma aldosterone and direct renin levels. These are the basic tests which we are required to do before we proceed with the evaluation further evaluation for adrenal mass. And of course, we also need to ensure that the patient is not on any drug which may influence these like any drugs in that sequence of renin , angiotensin and aldosterone. Another thing is DR levels. DR levels we only require if there is a bilateral adrenal mass or if we are suspecting there is a very large adrenal mass we are suspecting adrenal carcinoma. Then probably DR levels will also be required because the levels will be low in cases of adrenal insufficiency while it will be very high in cases of adrenal carcinoma. So, this additionally will be required if there is a bilateral adrenal mass or a larger adrenal mass. Right. So, now once you have a mass you have a biochemical confirmation. Is there any role for psychological evaluation using FNAC in adrenal masses? Actually there is no role of FNAC as far as adrenal masses are concerned because we want to know what is the functional status and the imaging clearly tells us about the benign and the malignant status. However, the FNAC may still be required in some cases whenever a malignancy is being suspected. So, we may do the FNAC if there is some other extra adrenal malignancy and in that case we may do the FNAC from the adrenal gland only if that if we know that the results of this FNAC is going to change our management. Otherwise there is no indication of FNAC in cases of adrenal masses. Also FNAC only is required to only should be done once the pheochromocytoma has been ruled out. Otherwise no FNAC should be tried unless and until the plasma metanephrines and non-metanephrines are absolutely normal. So, there is very less indication of FNAC in cases of adrenal masses. And even in primary adrenal carcinomas it should be avoided because it can see it. Right. So, now going back to imaging we discussed CT scan, but as far as adrenal medullary tumors are concerned there can be some imaging which is available now which is better than that. Once we know that probably it is secreting it is a catecholamine secreting tumor and the imaging CT imaging is also shows the necrosis, the heterogenicity it is a large tumor. Then there are certain specialized investigation in the form of MIBG scan or the Drotanox scan which may pick up the pheochromocytoma or there is other masses close to it in the chest or in the abdomen which may present as paracanumas and secreting catecholamines. So, these are specialized investigations in the form of MIBG scan and the Drotanox scan which may help to localize a tumor very well because when we are operating we should be absolutely sure that we are dealing with this particular tumor and it is a catecholamines secreting tumor. Right. So, once we have confirmed the diagnosis and localize the tumor as well what are the indications for treatment and especially surgical treatment in such conditions? The surgery treatment whenever there is an adrenal mass which has been discovered incidentally so the treatment will depend upon number of aspects. First is the functional status. If the tumor is hormonally active, if it is secreting cortisol, if it is secreting mineralocorticoid or it is a catecholamines secreting tumor, irrespective of the size, irrespective of imaging characters the patient has to be operated if it is a functional tumor. But in case it is a nonfunctional tumor the hormonal profile is absolutely normal then the indications of treatment is only if the size is more than 4 centimeter. If the size is less than 4 centimeter maybe it is 3 centimeter then we can follow up the patient we need not do the surgery at that particular time. Why this 4 centimeter has come is because it has been seen that less than 4 centimeter the incidence of adrenocortical carcinoma is very less in the tumors which are less than 4 centimeter in size. But the risk of adrenocortical carcinomas increases up to 25 percent if the tumor is more than 4 centimeter further increases if the tumor is about 6 centimeter in size. So all masses if they are functional or if they are more than 4 centimeter in size are required to be operated. And what about the management of secondary hypertension because that is one of the commonest presentation of adrenal tumors. Now this secondary hypertension is very important if the patient comes with the patient is a young patient less than 20 years the patient is well of hypertension or more than 50 years it is a resistant hypertension requiring number of other drugs to manage the hypertension. If there is evidence of any target organ damage early target organ damage then the evaluation for secondary hypertension is to be done and one of the evaluation for secondary hypertension is to rule out a catecholamine secreting tumor. And because the importance of finding out the cause of secondary hypertension is these are curable causes of hypertension. If you treat the hypertension we are able to take the patient off the drugs or decrease the drugs to the minimum. Besides that if in cases of mineralocorticoid secreting tumor they may also have associated hypokalemia and its associated complications. So if we are able to treat this tumor if it is due to a mineralocorticoid secreting tumor we are able to treat the tumor treat hypertension cure hypertension as well as about the complications associated with hypokalemia. So in many conditions it will happen that this surgery is not required and that mass remains and often it may be non-functional also. So at least non-functional when we are assessing for the first time. So what is the follow up of these masses? So a number of times these are as already discussed these number of tumors are discovered incidentally on performance of imaging for some other reasons. So the patient is also is not in a proper frame of mind to get operated. So we have to explain it to the patient after we have assessed the functional status and the size of the patient. So the follow up of the patient will depend upon what is the size, size of the tumor. If the size is less than four centimeter we can follow up this patient. What are the imaging characteristics of the mass? If the mass is a lipid rich adenoma that is the harmful unit is less than minus ten or there is a good wash out of the tumor then we need not going for surgery at that particular time we can follow up the patient. Then the growth of the tumor, how the tumor has been growing over a period of time. For this we need to do the imaging again at six months and thereafter at one year. After one year if there has been no growth of the tumor or if the growth of the tumor is more than one centimeter in one year then we have to closely follow up the tumor for next two to three years. Functionally we have to assess the patient for functional status for five years. So every year annually we have to check for the function status of the patient. If for five years the tumor remains non-functional thereafter we stop following up these patients for functionality as well as for size. So I think that's been a very comprehensive discussion on a very select topic. This is not something which is often encountered in primary care practice but people and specifically our students should know because patients will have a lot of apprehensions and also when to refer and how to follow up is something that even our physicians should understand which this discussion has made quite clear and I am sure our students will have some questions on this and they will come back. We will be very happy to answer. So thank you very much Nareesh for bearing your time. We will come back to you for more such topics in future. Thank you so much.