Adrenal nodules are being increasingly identified on imaging studies (i.e., CT or MRI) obtained for other reasons. All identified adrenal nodules should be evaluated to determine whether they lead to over-production of hormones or might harbor a malignancy such as adrenocortical carcinoma.
Listen as Brenessa Lindeman, MD, and John Porterfield, MD, discuss what to do if a nodule is found, including when surgery might be indicated.
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Adrenal Evaluation & Treatment
Featuring:
Learn more about Brenessa Lindeman, MD
Dr. John Porterfield joined the UAB Department of Surgery in 2008, returning to Alabama, his home state, after training at the Mayo Clinic. He has since achieved associate professorship and additionally serves as director of the General Surgery Residency Program. Dr. Porterfield speaks nationally and internationally regarding his expertise in surgical education, endocrine and robotic surgery.
Learn more about John Porterfield, MD
John Porterfield, MD | Brenessa Lindeman, MD
Dr. Brenessa Lindeman is a native of Kentucky, receiving her M.D. from Vanderbilt, and is a member of Alpha Omega Alpha. She did her residency in general surgery at Johns Hopkins University and completed a fellowship in endocrine surgery at the Harvard/Brigham and Women’s Hospital.Learn more about Brenessa Lindeman, MD
Dr. John Porterfield joined the UAB Department of Surgery in 2008, returning to Alabama, his home state, after training at the Mayo Clinic. He has since achieved associate professorship and additionally serves as director of the General Surgery Residency Program. Dr. Porterfield speaks nationally and internationally regarding his expertise in surgical education, endocrine and robotic surgery.
Learn more about John Porterfield, MD
Release Date: October 26, 2018
Expiration Date: October 26, 2021
Disclosure Information:
Dr. Porterfield has the following financial relationships with commercial interests:
Honorarium/Payment for Lectures, including service on Speakers Bureaus - Intuitive Surgical
Dr. Porterfield does not intend to discuss the off-label use of a product. No other speakers, planners or content reviewers have any relevant financial relationships to disclose.
There is no commercial support for this activity.
Expiration Date: October 26, 2021
Disclosure Information:
Dr. Porterfield has the following financial relationships with commercial interests:
Dr. Porterfield does not intend to discuss the off-label use of a product. No other speakers, planners or content reviewers have any relevant financial relationships to disclose.
There is no commercial support for this activity.
Transcription:
UAB Med Cast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.
Melanie Cole (Host): Welcome. Today, we are talking about adrenal evaluation and treatment and my guests are Dr. Brenessa Lindeman and Dr. John Porterfield. Both endocrine surgeons at UAB Medicine. Dr. Porterfield, I’m going to start with you to tell us a little bit about the adrenal glands. What does the adrenal cortex produce and what are some of the most common syndromes that you see?
John Porterfield, Jr., MD (Guest): Yes, so the adrenal glands are organs that sit in the back of the upper portion of the abdomen and it’s really made up of two layers. The outer layer, the cortex and the medulla and together they work together with the entire endocrine system throughout our entire body to be able to have our hormonal balance in an appropriate state of health. The cortex specifically as you asked about primarily makes three different groups of hormones. One is aldosterone, the other one is cortisol, then the other ones are the androgen or sex hormones and those can all be present in disease states if there’s a tumor that creates too much of any of those hormones coming from those layers.
Melanie: Dr. Lindeman when you are evaluating the adrenals, are you always looking for a mass or is it sometimes incidental and you come across it when you are testing for other things?
Brenessa Lindeman, MD (Guest): You know historically, patients that had over-secretion of one of the hormone products of the adrenal gland would come to attention based on the symptoms that they had. So, for patients with hypersecretion of aldosterone for example; they would have high blood pressure, and would be found to have a low potassium on their blood chemistry or some patients that had central obesity and other symptoms that go along with steroid hormone excess specifically cortisol; would then be able to be diagnosed with Cushing’s syndrome and then undergo workup to determine if that was due to overproduction from the adrenal glands or another cause. But I would say that today, the majority of patients come to our attention because of what’s been termed an adrenal incidentaloma and that is simply a mass within the adrenal gland that was found on an imaging study performed for a different reason. Found incidentally. And we’ve seen that as the number of people that are getting what are called cross sectional imaging studies like CT scans and MRIs have increased such that we see adrenal nodules or masses in about one out of every ten people.
Dr. Porterfield: And I would like to add that we find with these advanced cross-sectional imaging studies that we can often find things in different organs in the body that might be so small that we can’t characterize them. So, for these adrenal incidentalomas; we have decided based on the evidence of prior studies because we don’t want to ever miss the feared adrenal cortical carcinoma; which can be a deadly cancer; that we would evaluate all incidentalomas discovered in the adrenal glands that were bigger than one centimeter. So, one centimeter is our cut off for where we would want to begin the further evaluation clinically as well as the biochemical testing that Dr. Lindeman referenced.
Melanie: So, as I see it Dr. Porterfield, there’s two main questions and diagnostic criteria whether the lesion is malignant or whether it’s hormonally active. What are you watching for as primary adrenal cortical carcinomas and functional adenomas, so they are not missed?
Dr. Porterfield: Right, so, whenever we are looking at any of these lesions; we certainly want to rule out first and foremost that it’s not a cancer and so we do that largely based on its appearance on CT or MRI imaging as well as based on its size. If we have any opportunity to see it, at more than one point in time, we can then assess a rate of growth to be able to know if it’s growing at a rate that would be concerning. Certainly, something that’s growing more than one centimeter a year would be worrisome and then that is where we also have our upper limit of things that we watch. So, we watch things up until four centimeters. Beyond four centimeters, in otherwise healthy patients, particularly young patients; we become much more wary of watching them because we know from numerous previous studies that as the size of the tumor increases; the risk of it being an adrenal cortical carcinoma goes up.
Dr. Lindeman: And I would like to add to what Dr. Porterfield said that our techniques for imaging have become increasingly advanced over time such they we are beginning to be able to pick up concerning features within adrenal masses that don’t necessarily meet size criteria to indicate they would need to be removed. But the features that we become concerned about are adrenal masses of any size that demonstrate necrosis or calcification and also the radiologists can perform a measurement of the density of the adrenal tissue and if that density is very low; using something called Hounsfield units; if that value is less than ten, then we can be much more reassured that that adrenal mass is benign.
Melanie: Dr. Porterfield speak a little bit about follow up care and follow up visits for evaluation.
Dr. Porterfield: If we were to see a patient that had a lesion that was nonfunctional and less than four centimeters; then yes, we would want to see them back in clinic typically between six months and a year to repeat that imaging at least one time to be able to see that the lesion is stable. And we also can reference guidelines for how we follow these lesions based on their size and function.
Melanie: Dr. Lindeman speak about treatment a little bit. What are some current issues in medical or surgical management? Assess for us the appropriateness of specific treatments that you might use once you detect what’s going on as far as hormones, chemo, radiation, surgery.
Dr. Lindeman: Okay. That’s a large area, but I will attempt to go through it systematically. So, the way that I start to think about treatment for these adrenal lesions begins with the two questions that you posed previously. So, first, is the mass functional in some way that it’s overproducing hormones normally made by the adrenal glands? And so, if that’s the case; then surgical resection of the adrenal gland containing that mass is indicated and there are a couple of ways in which patients with certain types of hormone overproduction need to be prepared. For patients with hyperaldosteronism; it’s important to ensure that their electrolyte levels which can be thrown off because of the disease are within normal limits. Particularly for safety with anesthesia. For patients with cortisol overproduction; we want to make sure that we give those patients appropriate stress doses of steroids throughout the entire perioperative period and continue their steroid hormone replacement after surgery. And particularly for patients with pheochromocytoma, which is a tumor that produces excess catecholamines like epinephrine or norepinephrine. Those patients can have extreme hemodynamic changes intraoperatively with hypertension as the tumor is being manipulated prior to the vein drainage of the adrenal being ligated and those patients can also develop hypotension once the tumor has been removed and so we work very closely with our anesthesiologists to ensure that we have the patient adequately blocked in terms of alpha-blockade followed by beta blockade in the preoperative setting as well as ensuring we have appropriate monitoring and vasoactive agents available during the course of the operation.
Dr. Porterfield: And I would like to add that just over the last ten years; our anesthesia colleagues particularly here at UAB which we typically do most of these cases combined with are cardiac anesthesiologists that, they have become extremely skilled at being able to maintain the patients with a stable heart rate and a stable blood pressure while we are operating and we communicate with the anesthesiologist as we manipulate these tumors because we can realize that we might press on the tumor in a way that might cause more of the norepinephrine or epinephrine to be released from the actual gland itself as we are working on it, that will then obviously raise or if we were – raise the blood pressure and heart rate or if we were to take that pressure off; or as we are completing the case and we are dividing those last veins that Dr. Lindeman mentioned; those last tiny little tributaries, we want to avoid that low blood pressure which is also that risk point that she mentioned. And so, there’s been some advances with some IV drugs that we use particularly IV calcium channel blockers which have allowed us to be able to if you will, drive with our foot on the brake and the gas at the same time which has been able to allow our anesthesiologists to be able to really titrate these patients even with very large lesions into a very smooth intraoperative path that has yielded fantastic results to the point now where we have been able to for the first time, be able to allow some of these patients even with pheochromocytomas to even go home the same day.
Melanie: Dr. Lindeman speak about treatment for masses suspicious for or proven to be adrenal cortical carcinoma.
Dr. Lindeman: Oh yes. And that’s one thing that I omitted from my answer to your prior question. Which is in discussing the treatment of masses suspicious for or proven to be adrenal cortical carcinoma. And there had been controversy in the literature regarding the optimal approach for treatment of these tumors. Although, it’s been shown now that the single most important factor for treatment of adrenal cortical carcinoma is achievement of surgical resection with wide negative margins. So, meaning getting out the entire tumor with a relatively thick rim of normal tissue surrounding it ensuring that there’s no violation of that tumor capsule that may lead to spread or seeding of adrenal tumor cells. And as surgical techniques have advanced; many surgeons including Dr. Porterfield and myself find that we can accomplish operations even for adrenal cortical carcinoma using minimally invasive techniques other than in the most advanced cases with the largest tumor sizes. And so, I think one of the things that our colleagues can do to help patients prepare for surgery and deal with effects of it are to really have an understanding of whether the patient is a candidate for a minimally invasive approach and I know I can speak for Dr. Porterfield as well in saying that we are always happy to see any patient in the clinic if there is ever a question and guide them through that discussion of what the risks and benefits are for various approaches.
Dr. Porterfield: And I would like to add I completely agree with Dr. Lindeman that I have seen patients that have not been referred to us for adrenal surgery, because of their age or because of the size of the tumor and the provider felt like that the patient might be too old or the patient might be too ill or the tumor might be too big to be done in a minimally invasive fashion and what I would just beg would be for us to at least be able to see the patient and have that conversation with them. Because I think that what we have been able to do in a minimally invasive fashion, I don’t think we have quite reached the limit of what we can do. We have removed tumors larger than 14 and 15 centimeters with minimally invasive techniques particularly laparoscopy and with the advent of robotic surgery, it was once thought when Dr. Lindeman mentioned it was controversial.
It was once thought by from a more historical perspective that the surgery could be done more oncologically or following oncologic principles like she talked about getting that nice rim of healthy tissue around the adrenal gland. It was proposed that that could be done better with an open operation, but I would really contest now, and I know Dr. Lindeman agrees that the view that we have laparoscopically or robotically now is better than the view that I have open and we are able to meticulously protect that capsule that she mentioned and we are also able to meticulously evaluate the other structures around the adrenal glands, questioning for invasion and even if they are invaded. So, if a portion of the kidney is involved; then we have our urologist, we have performed partial nephrectomies, we have performed total nephrectomies, we have done distal pancreatectomies, splenectomies. We have removed portions of the stomach. We have done all of those things including portions of the colon and the small intestines, we have been able to remove large tumors with multiple organ resections and still not have to make a big open incision.
So, I think that it’s an exciting time to see how the technology has assisted us at being more precise cancer surgeons. Because we treat every adrenal tumor as if it’s a cancer until proven otherwise. Even if it’s a low likelihood; because we can’t ever go back and do the right operation the second time. We only get one chance to do it right.
Melanie: Dr. Lindeman first last word to you. Tell other providers what you’d like them to know about adrenal nodules and hyperproduction of hormones and really what you want them to know as referring physicians.
Dr. Lindeman: Absolutely. Thank you. I think one of the important things that referring physicians should know is that surgically correctable causes of hypertension, are very common in the general population. We believe that ten to potentially up to 15% of patients with high blood pressure may have hormone overproduction in terms of hyperaldosteronism and so I think it’s important for any provider that sees a patient with high blood pressure and with a low potassium to at least consider hyperaldosteronism as a diagnosis and to start that hormonal work up. I think the other thing that I would add to what Dr. Porterfield has described in terms of advances in surgical techniques is that here at UAB, we offer all of the potential minimally invasive techniques that surgeons are doing in this modern era and can customize that approach to the patient’s needs. So, he had mentioned laparoscopic and robotic approaches and we are also able to perform a retroperitoneoscopic approach to adrenalectomy in which patients a laying in the prone position and we are able to take a much more direct approach to the adrenal gland through the back and this is a very useful approach because it allows a direct and quicker access to the adrenal gland. It allows us to avoid re-entry into the peritoneal cavity in patients that have had prior surgery that may have led to the formation of scar tissue that might make that operation more complicated or risky and it also eliminates the need to reposition the patient if they are in need of a bilateral adrenalectomy. And so, working together, in our multidisciplinary way; we can see and evaluate the patient and determine which of those approaches that they may be best suited for. Because they all have an excellent recovery. They are all procedures that we are now performing for many patients on an outpatient basis. But, we can work with patients to determine their personal risk and benefit profiles and which surgical approach would be best for them.
Melanie: Dr. Porterfield, last word to you now. What does current research indicate for future developments in treatments and give us your best advice and information for other providers and what you would like them to know about adrenal evaluation and treatment.
Dr. Porterfield: Thank you Melanie. So, I think the most important thing that I would like to leave with providers is I would just request that they please not biopsy and adrenal gland. We would really like the opportunity to see those patients before a biopsy is entertained. There are some catastrophic examples that occur each year when adrenal glands are biopsied without a complete biochemical evaluation preoperatively and that can be disastrous if someone was to inadvertently biopsy a pheochromocytoma. It can also make the operation, the subsequent operation more difficult because adrenal glands can tend to bleed at the time of a biopsy and that can make the operation more difficult. It can also make the evaluation by our pathologist more difficult if they are having to look around the tumor, looking for areas that might be – might have had some areas of invasion, but yet there was adrenal hemorrhage related to a biopsy, that can be challenging. So, my final word would be please don’t biopsy an adrenal gland without speaking with a endocrine surgeon about the safety of it because the reality is that if the tumor is large, it’s going to come out, if it is functional; we are going to recommend that it come out. One of the things that I don’t think we mentioned yet is oftentimes patients are getting PET scans for other malignancies and so if there is a lesion on a PET scan in an adrenal gland that is PET positive; we are also going to recommend removal of that adrenal gland as part of – because of the risk that we know with PET positive lesions; there is more risk of malignancy in those tumors than in PET negative adrenal masses. So, that would be my main take home point is if there is ever a question of a biopsy, call Dr. Lindeman, call myself. We would be more than happy to go over the details of the case. There are a few rare examples where a biopsy can be valuable, and we have some unique ways to do that even through the stomach or through the duodenum and to not have to go through percutaneous routes which have been done in the past. So, we can connect them with the most appropriate team that would be able to do that in the safest way possible in the rarest of events that an adrenal biopsy would be indicated.
Dr. Lindeman: And I would like to add to what Dr. Porterfield was describing particularly in terms of thinking about adrenal gland biopsy and masses that are identified with PET scans. Historically, one of the indications for adrenal biopsy was in a patient with a known history of malignancy in whom you suspect they have a metastasis, but as more and more of these patients are being followed with PET scans; PET avid adrenal masses that are identified that are suspicious for metastatic disease are another group of patients that we would love to have the opportunity to evaluate and discuss with you as the referring provider and with the patient because over time; what the literature has begun to demonstrate is that patients will have a survival benefit for resection of isolated adrenal metastases for lung cancer, for renal cell carcinoma and others with a one year survival of around 60% and a five year survival in patients with metastatic disease of up to 28% in some studies. So, I think that’s another way in which the field is continuing to expand for the benefit of our patients.
Melanie: Thank you so much both of you for joining us today and sharing your expertise about adrenal evaluation and treatment and letting other providers know how important it is that they do refer a patient before they start some treatment and evaluation. Thank you again for being with us. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That’s 1-800-822-6478. You’re listening to UAB Med Cast. For more information on resources available at UAB Medicine you can go to www.uabmedicine.org/physician, that’s www.uabmedicine.org/physician. This is Melanie Cole. Thanks so much for listening.
UAB Med Cast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.
Melanie Cole (Host): Welcome. Today, we are talking about adrenal evaluation and treatment and my guests are Dr. Brenessa Lindeman and Dr. John Porterfield. Both endocrine surgeons at UAB Medicine. Dr. Porterfield, I’m going to start with you to tell us a little bit about the adrenal glands. What does the adrenal cortex produce and what are some of the most common syndromes that you see?
John Porterfield, Jr., MD (Guest): Yes, so the adrenal glands are organs that sit in the back of the upper portion of the abdomen and it’s really made up of two layers. The outer layer, the cortex and the medulla and together they work together with the entire endocrine system throughout our entire body to be able to have our hormonal balance in an appropriate state of health. The cortex specifically as you asked about primarily makes three different groups of hormones. One is aldosterone, the other one is cortisol, then the other ones are the androgen or sex hormones and those can all be present in disease states if there’s a tumor that creates too much of any of those hormones coming from those layers.
Melanie: Dr. Lindeman when you are evaluating the adrenals, are you always looking for a mass or is it sometimes incidental and you come across it when you are testing for other things?
Brenessa Lindeman, MD (Guest): You know historically, patients that had over-secretion of one of the hormone products of the adrenal gland would come to attention based on the symptoms that they had. So, for patients with hypersecretion of aldosterone for example; they would have high blood pressure, and would be found to have a low potassium on their blood chemistry or some patients that had central obesity and other symptoms that go along with steroid hormone excess specifically cortisol; would then be able to be diagnosed with Cushing’s syndrome and then undergo workup to determine if that was due to overproduction from the adrenal glands or another cause. But I would say that today, the majority of patients come to our attention because of what’s been termed an adrenal incidentaloma and that is simply a mass within the adrenal gland that was found on an imaging study performed for a different reason. Found incidentally. And we’ve seen that as the number of people that are getting what are called cross sectional imaging studies like CT scans and MRIs have increased such that we see adrenal nodules or masses in about one out of every ten people.
Dr. Porterfield: And I would like to add that we find with these advanced cross-sectional imaging studies that we can often find things in different organs in the body that might be so small that we can’t characterize them. So, for these adrenal incidentalomas; we have decided based on the evidence of prior studies because we don’t want to ever miss the feared adrenal cortical carcinoma; which can be a deadly cancer; that we would evaluate all incidentalomas discovered in the adrenal glands that were bigger than one centimeter. So, one centimeter is our cut off for where we would want to begin the further evaluation clinically as well as the biochemical testing that Dr. Lindeman referenced.
Melanie: So, as I see it Dr. Porterfield, there’s two main questions and diagnostic criteria whether the lesion is malignant or whether it’s hormonally active. What are you watching for as primary adrenal cortical carcinomas and functional adenomas, so they are not missed?
Dr. Porterfield: Right, so, whenever we are looking at any of these lesions; we certainly want to rule out first and foremost that it’s not a cancer and so we do that largely based on its appearance on CT or MRI imaging as well as based on its size. If we have any opportunity to see it, at more than one point in time, we can then assess a rate of growth to be able to know if it’s growing at a rate that would be concerning. Certainly, something that’s growing more than one centimeter a year would be worrisome and then that is where we also have our upper limit of things that we watch. So, we watch things up until four centimeters. Beyond four centimeters, in otherwise healthy patients, particularly young patients; we become much more wary of watching them because we know from numerous previous studies that as the size of the tumor increases; the risk of it being an adrenal cortical carcinoma goes up.
Dr. Lindeman: And I would like to add to what Dr. Porterfield said that our techniques for imaging have become increasingly advanced over time such they we are beginning to be able to pick up concerning features within adrenal masses that don’t necessarily meet size criteria to indicate they would need to be removed. But the features that we become concerned about are adrenal masses of any size that demonstrate necrosis or calcification and also the radiologists can perform a measurement of the density of the adrenal tissue and if that density is very low; using something called Hounsfield units; if that value is less than ten, then we can be much more reassured that that adrenal mass is benign.
Melanie: Dr. Porterfield speak a little bit about follow up care and follow up visits for evaluation.
Dr. Porterfield: If we were to see a patient that had a lesion that was nonfunctional and less than four centimeters; then yes, we would want to see them back in clinic typically between six months and a year to repeat that imaging at least one time to be able to see that the lesion is stable. And we also can reference guidelines for how we follow these lesions based on their size and function.
Melanie: Dr. Lindeman speak about treatment a little bit. What are some current issues in medical or surgical management? Assess for us the appropriateness of specific treatments that you might use once you detect what’s going on as far as hormones, chemo, radiation, surgery.
Dr. Lindeman: Okay. That’s a large area, but I will attempt to go through it systematically. So, the way that I start to think about treatment for these adrenal lesions begins with the two questions that you posed previously. So, first, is the mass functional in some way that it’s overproducing hormones normally made by the adrenal glands? And so, if that’s the case; then surgical resection of the adrenal gland containing that mass is indicated and there are a couple of ways in which patients with certain types of hormone overproduction need to be prepared. For patients with hyperaldosteronism; it’s important to ensure that their electrolyte levels which can be thrown off because of the disease are within normal limits. Particularly for safety with anesthesia. For patients with cortisol overproduction; we want to make sure that we give those patients appropriate stress doses of steroids throughout the entire perioperative period and continue their steroid hormone replacement after surgery. And particularly for patients with pheochromocytoma, which is a tumor that produces excess catecholamines like epinephrine or norepinephrine. Those patients can have extreme hemodynamic changes intraoperatively with hypertension as the tumor is being manipulated prior to the vein drainage of the adrenal being ligated and those patients can also develop hypotension once the tumor has been removed and so we work very closely with our anesthesiologists to ensure that we have the patient adequately blocked in terms of alpha-blockade followed by beta blockade in the preoperative setting as well as ensuring we have appropriate monitoring and vasoactive agents available during the course of the operation.
Dr. Porterfield: And I would like to add that just over the last ten years; our anesthesia colleagues particularly here at UAB which we typically do most of these cases combined with are cardiac anesthesiologists that, they have become extremely skilled at being able to maintain the patients with a stable heart rate and a stable blood pressure while we are operating and we communicate with the anesthesiologist as we manipulate these tumors because we can realize that we might press on the tumor in a way that might cause more of the norepinephrine or epinephrine to be released from the actual gland itself as we are working on it, that will then obviously raise or if we were – raise the blood pressure and heart rate or if we were to take that pressure off; or as we are completing the case and we are dividing those last veins that Dr. Lindeman mentioned; those last tiny little tributaries, we want to avoid that low blood pressure which is also that risk point that she mentioned. And so, there’s been some advances with some IV drugs that we use particularly IV calcium channel blockers which have allowed us to be able to if you will, drive with our foot on the brake and the gas at the same time which has been able to allow our anesthesiologists to be able to really titrate these patients even with very large lesions into a very smooth intraoperative path that has yielded fantastic results to the point now where we have been able to for the first time, be able to allow some of these patients even with pheochromocytomas to even go home the same day.
Melanie: Dr. Lindeman speak about treatment for masses suspicious for or proven to be adrenal cortical carcinoma.
Dr. Lindeman: Oh yes. And that’s one thing that I omitted from my answer to your prior question. Which is in discussing the treatment of masses suspicious for or proven to be adrenal cortical carcinoma. And there had been controversy in the literature regarding the optimal approach for treatment of these tumors. Although, it’s been shown now that the single most important factor for treatment of adrenal cortical carcinoma is achievement of surgical resection with wide negative margins. So, meaning getting out the entire tumor with a relatively thick rim of normal tissue surrounding it ensuring that there’s no violation of that tumor capsule that may lead to spread or seeding of adrenal tumor cells. And as surgical techniques have advanced; many surgeons including Dr. Porterfield and myself find that we can accomplish operations even for adrenal cortical carcinoma using minimally invasive techniques other than in the most advanced cases with the largest tumor sizes. And so, I think one of the things that our colleagues can do to help patients prepare for surgery and deal with effects of it are to really have an understanding of whether the patient is a candidate for a minimally invasive approach and I know I can speak for Dr. Porterfield as well in saying that we are always happy to see any patient in the clinic if there is ever a question and guide them through that discussion of what the risks and benefits are for various approaches.
Dr. Porterfield: And I would like to add I completely agree with Dr. Lindeman that I have seen patients that have not been referred to us for adrenal surgery, because of their age or because of the size of the tumor and the provider felt like that the patient might be too old or the patient might be too ill or the tumor might be too big to be done in a minimally invasive fashion and what I would just beg would be for us to at least be able to see the patient and have that conversation with them. Because I think that what we have been able to do in a minimally invasive fashion, I don’t think we have quite reached the limit of what we can do. We have removed tumors larger than 14 and 15 centimeters with minimally invasive techniques particularly laparoscopy and with the advent of robotic surgery, it was once thought when Dr. Lindeman mentioned it was controversial.
It was once thought by from a more historical perspective that the surgery could be done more oncologically or following oncologic principles like she talked about getting that nice rim of healthy tissue around the adrenal gland. It was proposed that that could be done better with an open operation, but I would really contest now, and I know Dr. Lindeman agrees that the view that we have laparoscopically or robotically now is better than the view that I have open and we are able to meticulously protect that capsule that she mentioned and we are also able to meticulously evaluate the other structures around the adrenal glands, questioning for invasion and even if they are invaded. So, if a portion of the kidney is involved; then we have our urologist, we have performed partial nephrectomies, we have performed total nephrectomies, we have done distal pancreatectomies, splenectomies. We have removed portions of the stomach. We have done all of those things including portions of the colon and the small intestines, we have been able to remove large tumors with multiple organ resections and still not have to make a big open incision.
So, I think that it’s an exciting time to see how the technology has assisted us at being more precise cancer surgeons. Because we treat every adrenal tumor as if it’s a cancer until proven otherwise. Even if it’s a low likelihood; because we can’t ever go back and do the right operation the second time. We only get one chance to do it right.
Melanie: Dr. Lindeman first last word to you. Tell other providers what you’d like them to know about adrenal nodules and hyperproduction of hormones and really what you want them to know as referring physicians.
Dr. Lindeman: Absolutely. Thank you. I think one of the important things that referring physicians should know is that surgically correctable causes of hypertension, are very common in the general population. We believe that ten to potentially up to 15% of patients with high blood pressure may have hormone overproduction in terms of hyperaldosteronism and so I think it’s important for any provider that sees a patient with high blood pressure and with a low potassium to at least consider hyperaldosteronism as a diagnosis and to start that hormonal work up. I think the other thing that I would add to what Dr. Porterfield has described in terms of advances in surgical techniques is that here at UAB, we offer all of the potential minimally invasive techniques that surgeons are doing in this modern era and can customize that approach to the patient’s needs. So, he had mentioned laparoscopic and robotic approaches and we are also able to perform a retroperitoneoscopic approach to adrenalectomy in which patients a laying in the prone position and we are able to take a much more direct approach to the adrenal gland through the back and this is a very useful approach because it allows a direct and quicker access to the adrenal gland. It allows us to avoid re-entry into the peritoneal cavity in patients that have had prior surgery that may have led to the formation of scar tissue that might make that operation more complicated or risky and it also eliminates the need to reposition the patient if they are in need of a bilateral adrenalectomy. And so, working together, in our multidisciplinary way; we can see and evaluate the patient and determine which of those approaches that they may be best suited for. Because they all have an excellent recovery. They are all procedures that we are now performing for many patients on an outpatient basis. But, we can work with patients to determine their personal risk and benefit profiles and which surgical approach would be best for them.
Melanie: Dr. Porterfield, last word to you now. What does current research indicate for future developments in treatments and give us your best advice and information for other providers and what you would like them to know about adrenal evaluation and treatment.
Dr. Porterfield: Thank you Melanie. So, I think the most important thing that I would like to leave with providers is I would just request that they please not biopsy and adrenal gland. We would really like the opportunity to see those patients before a biopsy is entertained. There are some catastrophic examples that occur each year when adrenal glands are biopsied without a complete biochemical evaluation preoperatively and that can be disastrous if someone was to inadvertently biopsy a pheochromocytoma. It can also make the operation, the subsequent operation more difficult because adrenal glands can tend to bleed at the time of a biopsy and that can make the operation more difficult. It can also make the evaluation by our pathologist more difficult if they are having to look around the tumor, looking for areas that might be – might have had some areas of invasion, but yet there was adrenal hemorrhage related to a biopsy, that can be challenging. So, my final word would be please don’t biopsy an adrenal gland without speaking with a endocrine surgeon about the safety of it because the reality is that if the tumor is large, it’s going to come out, if it is functional; we are going to recommend that it come out. One of the things that I don’t think we mentioned yet is oftentimes patients are getting PET scans for other malignancies and so if there is a lesion on a PET scan in an adrenal gland that is PET positive; we are also going to recommend removal of that adrenal gland as part of – because of the risk that we know with PET positive lesions; there is more risk of malignancy in those tumors than in PET negative adrenal masses. So, that would be my main take home point is if there is ever a question of a biopsy, call Dr. Lindeman, call myself. We would be more than happy to go over the details of the case. There are a few rare examples where a biopsy can be valuable, and we have some unique ways to do that even through the stomach or through the duodenum and to not have to go through percutaneous routes which have been done in the past. So, we can connect them with the most appropriate team that would be able to do that in the safest way possible in the rarest of events that an adrenal biopsy would be indicated.
Dr. Lindeman: And I would like to add to what Dr. Porterfield was describing particularly in terms of thinking about adrenal gland biopsy and masses that are identified with PET scans. Historically, one of the indications for adrenal biopsy was in a patient with a known history of malignancy in whom you suspect they have a metastasis, but as more and more of these patients are being followed with PET scans; PET avid adrenal masses that are identified that are suspicious for metastatic disease are another group of patients that we would love to have the opportunity to evaluate and discuss with you as the referring provider and with the patient because over time; what the literature has begun to demonstrate is that patients will have a survival benefit for resection of isolated adrenal metastases for lung cancer, for renal cell carcinoma and others with a one year survival of around 60% and a five year survival in patients with metastatic disease of up to 28% in some studies. So, I think that’s another way in which the field is continuing to expand for the benefit of our patients.
Melanie: Thank you so much both of you for joining us today and sharing your expertise about adrenal evaluation and treatment and letting other providers know how important it is that they do refer a patient before they start some treatment and evaluation. Thank you again for being with us. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That’s 1-800-822-6478. You’re listening to UAB Med Cast. For more information on resources available at UAB Medicine you can go to www.uabmedicine.org/physician, that’s www.uabmedicine.org/physician. This is Melanie Cole. Thanks so much for listening.