Adrenal Tumor Surgery

When surgery is needed

Surgery is recommended:

• for pheochromocytoma — a tumor that produces adrenaline and noradrenaline;
• for aldosteronoma with unilateral aldosterone production;
• for overt cortisol excess; with mild autonomous cortisol secretion and related conditions, surgery is discussed individually by a tumor board;
• for signs of possible malignancy on CT or MRI;
• if the tumor grows noticeably — by more than 20% and at least 5 mm within 6–12 months.

Small nonfunctioning adenomas with typical CT features do not need surgery and often not even further follow-up. A solitary metastasis to the adrenal gland is sometimes removed if the primary tumor is under control. The disease itself and the types of tumors are described on the page “Adrenal Tumors”.

What must be done before surgery

• non-contrast CT — the density of the mass: a homogeneous mass with a density of up to 10 Hounsfield units practically confirms a benign adenoma; if the density is higher — contrast CT with washout assessment or MRI;
• the 1 mg dexamethasone test — to look for cortisol excess;
• metanephrines in plasma or urine — to rule out pheochromocytoma; mandatory before any procedure on a mass that is not clearly an adenoma;
• aldosterone and renin — with high blood pressure or low potassium; if positive — confirmatory tests and often adrenal vein sampling to determine which side the excess comes from;
• if adrenocortical carcinoma is suspected — additional assessment of steroid hormones and their precursors and staging tests, including chest CT.

Adrenal biopsy is not performed when a primary tumor is suspected: it cannot distinguish an adenoma from cancer and may cause tumor spread. It is done only when a metastasis is suspected, when the result will change treatment, and only after pheochromocytoma has been ruled out.

Preparation for pheochromocytoma

For 1–2 weeks before surgery alpha-blockers are taken and fluid and salt intake are increased. This prepares the blood vessels for the disappearance of the excess hormones and reduces the risk of sharp blood pressure spikes during tumor removal and a drop afterwards. A substantial share of pheochromocytomas have a hereditary basis, so genetic counseling is recommended for these patients.

Types of adrenal surgery

How the operation is performed

Laparoscopic adrenalectomy is the standard for benign tumors and most pheochromocytomas: the adrenal gland is removed through a few small incisions. I choose the approach based on the size and location of the tumor, its hormonal activity and previous operations.

When adrenocortical carcinoma is suspected, especially with signs of invasion, the tumor is usually removed by open surgery, en bloc with the surrounding fat and lymph nodes and, when needed, with part of the kidney, liver or a vein, without breaching the capsule: the completeness of the first operation matters most for the outcome.

Hospital stay, recovery and follow-up

Recovery follows the enhanced recovery (ERAS) protocol: early mobilization, early eating, controlled pain relief. After laparoscopic adrenalectomy the patient is usually discharged within a few days.

After removal of a cortisol-producing tumor the other adrenal gland is “dormant” for a while, so hydrocortisone is prescribed temporarily and withdrawn gradually, after laboratory confirmation of recovery. After removal of an aldosteronoma potassium and blood pressure are monitored, after pheochromocytoma — blood pressure and glucose. One healthy adrenal gland is usually enough for a normal life.

After pheochromocytoma, metanephrines are checked every year for at least 10 years, and lifelong in high-risk groups, including hereditary forms, young age or a large tumor. After adrenocortical carcinoma, CT is done every 3 months for the first 2 years, then less often. After removal of a benign adenoma follow-up is usually not needed, apart from monitoring the hormonal effect.

Risks and complications

Risks are what patients ask about least often, although they are the most important thing to discuss before surgery. The main ones are:

• blood pressure swings during and after removal of a pheochromocytoma — which is why preparation is needed;
• temporary adrenal insufficiency after removal of a cortisol-producing tumor — which is why hydrocortisone is prescribed;
• bleeding during or after surgery;
• infection and general surgical complications, including thrombosis.

The likelihood of each depends on the type of tumor, its size, the approach and other conditions. I will explain the risks in your particular case at the consultation.

What the cost depends on

The cost depends on the approach — laparoscopic or open — the extent of surgery, the number of days in the hospital, and the tests and preparation for it. The exact amount is named once the treatment plan has been defined. The payment can be split into parts — installments are available. The in-person consultation is free. More details are on the page “Cost of Surgery: What It Depends On”.

What documents are needed and how to book

• CT or MRI discs with the reports, including non-contrast CT with the density of the mass;
• hormone test results: dexamethasone test, metanephrines, aldosterone and renin, potassium;
• a list of medications, especially for blood pressure;
• summaries about the primary cancer, if a metastasis is suspected;
• information about adrenal or endocrine tumors in the family.

Book a consultation by phone or through the form. If you are from another city, send the documents in advance — how to do this is described on the page “Online Oncologist Consultation”.