Aldosterone-secreting

-consider echocardiogram

-consider adrenal vein sampling, but almost definitely not beneficial in patients <40 yo with clear unilateral adenoma on imaging

-consider genetic testing

Total adrenalectomy (partial adrenalectomy discouraged due to high prevalence of multifocal disease in affected gland)

Postop: high sodium diet, monitor for hyperkalemia, measure aldosterone-to-renin ratio

Cortisol-secreting

Consider workup for:

-diabetes

-hypertension

-osteoporosis, including asymptomatic vertebral fractures

-urolithiasis

-hypogonadotropic hypogonadism

-Signs/symptoms of Cushing syndrome -> resection

-Autonomous cortisol secretion w/o Cushing -> controversial. resection vs observation

Postop: monitor vitals for signs of Addisonian crisis, consider glucocorticoid supplementation

Pheochromocytoma

germline genetic testing

r/o extra-adrenal disease:

-usually FDG-PET (or 68Ga-DOTATATE PET if available)

-MIBG if MEN-2 germline mutation or excess norepi/normeta w/o excess epi/meta

Resection

Preop: alpha blockade. hydration day before

Postop: usually ICU monitoring.

-BP

-blood glucose (rebound hyperinsulinemia)

-aggressive IV fluid and glucose repletion

Early adrenal vein ligation

Minimize tumor manipulation

MIS or open ok

Total or partial ok

Hormonally inactive, not suspicious for ACC

See “Imaging Assessment”

Suspected Adrenocortical Carcinoma (including androgen-secreting)

Metastatic workup

Resection

Often adjuvant radiotherapy or mitotane

If metastatic, still consider resection with metastatectomy if >90% of tumor burden can be removed

Aggressive resection with en-bloc resection of organs subject to local invasion

MIS vs open is controversial

Lymph node dissection optional

Myelolipoma

None. (even need for metabolic work up is somewhat controversial)

Observation usually

Consider resection if very large (>10cm) to decrease risk of spontaneous hemorrhage or if symptomatic

MIS preferred if resection is undertaken

Adrenal cysts

None

Controversial. Generally favor resection if >4-5cm

Adrenal oncocytoma

None. Diagnosis rarely made preoperatively

Resection

Ganglioneuroma

Resection