Adrenal tumor

The adrenal gland is a small organ 4-6 gm approximately, 4x3x1 centimeters, and yellow. The adrenal gland is located above the two kidneys (as shown in the picture). It produces hormones that respond to stress in the body including Aero, Cortisol, and Adrenaline.

Each gland has the Medulla and the Cortex.

The substance that is secreted from the medulla is Epinephrine or Adrenaline, which influences the function of the heart muscle and a small muscle on the wall of blood vessels giving sufficient pressure to allow the blood to circulate according to the needs of the body. It also stimulates the autonomic sympathetic nervous system and help to increase sugar levels. It provides the opposite effect to Insulin.

The hormone secreted from the adrenal cortex contains about 30 compounds called steroids, which is different to Einone. One of the compounds is an aldosterone. It helps regulate calcium, potassium and water distribution in the body. Cortisone and Hydrochloric helps regulate the metabolism of proteins, carbohydrates, fats and regulates reaction caused by inflammation and immunity. The other species is Androsterone is Testosterone, which is a hormone that will make the appearance of the male, but it is found in both genders.

Therefore, adrenal tumor usually causes hormonal symptoms as what the tumor is produced, such as when the patient has adrenal tumors that produce adrenaline hormone, it will cause the patient to have high blood pressure, headache, sweating, tremor, etc.

Benign Adrenal tumor

1. Primary Hyperaldosteronism (Conn’s syndrome) is usually caused by Adrenocortical adenoma. The most important symptom is High Blood Pressure, In general, the blood pressure will be at the middle high level. Many dosage regimens are required. The second symptom is muscle weakness or numbness because of loss of salt to the urine (Hypokalemia). The third symptom is frequent urination, urination while sleeping, and frequent thirst. Those who find that the body has any discomfort, especially those with high blood pressure should pay attention to visit a standard hospital immediately in order to avoid more harmful.

 2. Cushing's syndrome is caused by high levels of steroid hormones in the blood. This is mainly due to the long-term use of steroids, such as the treatment of patients with SLE, rheumatoid arthritis, or chronic kidney disease or use of medicine set with steroids for a long time. It is rarely found the case when adrenocortical adenoma produces abnormal steroid hormones. This may be because of adrenal tumors or pituitary tumor (which stimulates the adrenal glands to over-work), or other tumors (such as lung, ovarian, liver, or kidney cancer) that produce hormones that stimulate the adrenal glands to work. Cushing's disease is not caused by the use of steroids. It is very rare. It is found in middle-aged women. The probability of detecting this disease in females is 5 times more than males. Symptoms usually develop slowly over the course of months. In the initial period, the patient’s face will be rounded like a moon and reddish, fat lumps occur at the back of the neck (Between the both shoulders) like a hump. Medical term is Buffalo's hump. The patient is very fat in the waist (puffy belly), but limbs are diminished. Patients will feel fatigued, tired and depressed. The skin is dark in the belly (like postpartum belly) and skin at the hip is thin and green, it is easy to shrink when it is concussed, there is often with acne and more hairs on the fact (If found in women, it makes them look like a mustache. Bones in the Body and limb bone may erosion and usually causes back pain. (because the vertebral decay). Patient may have high blood pressure. Women with diabetes may have a hoarse voice and is very hairy like a man. The menstrual period is usually less or not at all. Patients may have mood swings or become psychotic or have no sexual feelings

3. Pheochromocytoma occurs in the medulla of adrenal glands. 80% is found in one side, 10% is found in both side, 10% is found in other organs. There is a 10% chance of malignant adenoma. Regardless of location, Pheochromocytoma will secrete, adrenaline and noradrenaline hormone causing tremor, tingling pulse, high blood pressure, arrhythmia, sweating, anxiety, weight loss, even if the tumor is not malignant, but the excessive hormones creates problem seriously and sometimes it comes out in large quantities causing blood pressure becoming high quickly. It can lead to stroke and the patient can die. Therefore, it is necessary to detect the tumor position and remove it by surgery.

Malignant Adrenal tumors

Adrenocortical Carcinoma is less common and difficult to diagnose because it is more likely to spread to other organs. The incidence rate is 2 per 1,000,000. It is more common in children and adults aged 40-50 years.

1. Adrenocortical Carcinoma is both hormone-producing (50%) and non-hormonal producing (50%). In non-functioning tumors, the symptoms are usually caused by pressure effects such as abdominal pain or back pain. Other symptoms that may be associated, such as weight loss, anorexia. In children, 90% will be virilization. The boy has a precocious puberty. There is gynecomastia, gonadal atrophy, loss of libido. The girls are virilization with hairy, but hair loss, abnormal menstruation.

2. Adrenal Metastases is 26-50%. The most common found is lung cancer and breast cancer, followed by stomach cancer , colon cancer, Thyroid cancer, kidney cancer, ovarian cancer, mole cancer, etc., but usually without symptom. CT will show that one or both adrenal glands are unequal in size, shadows, shape of the jumpy mass, unequal density. It can be easily developed to cyst with bleeding. This disease is usually coincidently found in CT for other causes. If the location of cancer is found, it is clearly diagnosed.

Diagnosis of Adrenal tumor

1. Special X-ray method to see the appearance of adenoma, distribution of lymph nodes, and pressing other organ which is near by such as scan , MRI , or PET. MIBG Scan may be applied to children with high blood pressure who are suspected to have neuroblatoma that produces the hormone so that the medulla can be seen.

2. diagnostic hormonal test by collecting the blood or urine throughout 24 hours. If abnormal hormone level is detected and even the x-ray result shows that it is normal adenoma, the surgery is needed anyway.

Treatment

Currently, adrenal adenomas have been reported that it is coincidently found in annual health checkup more. It is important for the physician to distinguish whether it is benign or malignant tumor and it is a functional tumor or not. Surgery is recommended for Adrenal incidentaloma that is larger than 4 centimeters because there is a chance of cancer around 10%

Commonly found functional tumor are primary hyperaldosteronism( Conn’s syndrome) , Cushing’s syndrome and Pheochromocytoma. In this case the surgery is needed regardless of the size.

1. perioperative medical management

2. Laparoscopic Adrenalectomy has been recognized as a gold standard, with the potential for open surgery to be less than 5% and a better outcome than open adrenalectomy, in terms of small incision, reduce death rate, and shorten the hospitalization.

3. Radiation therapy is often used to treat patients who have spread to the bone.

พญ. กมเลส ประสิทธิ์วรากุล

Surgeon of Laparoscopic Surgery Center,
Bangkok Hatyai Hospital

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