Hormonally Active Adrenal Tumors
Adrenal nodules are commonly discovered accidentally when patients have abdominal CT scans or MRI’s for other reasons. Almost all of these nodules are not cancerous, particularly if they are less than one inch (3 cm) in largest dimension. However, even small adrenal nodules can cause clinical symptoms by over-producing adrenal hormones like epinephrine, cortisol, aldosterone and testosterone.
Epinephrine is the body’s main acute stress hormone. This is the hormone that makes your heart feel like it is going to jump out of your chest when you narrowly avoid an automobile accident. Epinephrine or norepinephrine secreting tumors cause high blood pressure, diabetes, headaches, sweating and peculiar spells. Physicians call these tumors pheochromocytomas. They are quite unusual and cause less than 1% of the cases of hypertension seen in an endocrinologist’s office. Work-up for pheochromocytoma is complicated and requires blood specimens and 24 hour urine collections. Many drugs and some foods interfere with the pheochromocytoma work-up and must be taken into account by the evaluating endocrinologist. Surgical removal should only be attempted by experienced surgeons and anaesthesiologists, as pheochromocytoma patients tend to suffer wide swings of blood pressure during and after surgery. Pheochromocytoma surgery can be accomplished with minimal invasion using laparoscopic techniques if the tumor is solitary, less than 3 inches (8-9 cm) in size, and the surgeon has plenty of laparoscopic experience.
Cortisol is the body’s chronic stress hormone. Cortisol-secreting adrenal tumors present with diabetes, abdominal weight gain, high blood pressure, osteoporosis and muscle weakness. High cortisol levels over the long term are very detrimental to the immune response making affected patients prone to serious infections. Diagnosis is made by documenting chronic abnormal cortisol levels in blood and 24 hour urine collections. If the adrenal nodule is directly responsible for cortisol excess, it can being removed laparoscopically by a specially trained minimally invasive endocrine surgeon.
Aldosterone is a hormone that causes the body to hold onto salt and can raise blood pressure secondarily. Aldosterone-secreting adrenal tumors cause high blood pressure and low blood potassium levels. Diagnosis is made by documenting high blood aldosterone levels with low plasma renin concentrations after the patient has been standing for 30 minutes. Once the patient’s hormone levels are shown to be abnormal, then we must document that any adrenal nodule seen on MRI or CT is responsible for the hormone excess. This involves inserting a catheter into the right and the left adrenal veins from the groin and drawing blood samples for plasma aldosterone from each gland. If the aldosterone over-production is clearly on the same side as the adrenal nodule, then surgical excision of the nodule through a laparoscope should be curative.
Finally, adrenal tumors can produce sex hormones like DHEA and testosterone. These hormones cause women to become masculinized with the growth of coarse body hair on the face, abdomen, low back and legs. In addition, facial acne and hypertension may become a problem. Diagnosis is made by measuring blood testosterone and DHEA levels and performing adrenal catheterization to make sure that the excessive male hormone production is coming from the adrenal that contains the nodule. Laparoscopic adrenal removal is readily accomplished by an endocrine surgeon if the nodule is smaller than 3 inches in largest dimension.
| 
