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Forum Name: Endocrinology Topics

Question: Adrenal Adenoma and Kidney Lesion


 isoara - Sat Jun 19, 2010 5:32 pm

Oct. '08 [32 yrs old]-increased fatigue to the point of 'exhauted feeling'- by not doing anything, example: wake up, shower, need to sleep.
Dec. '08-first skin sores appeared on & around mouth/lips, dismissed myself as cold sores
Jan. '09- the same type of 'cold-sores' developed on my face, neck, back, arms, chest and legs. In the same time frame, I also started experiencing panic attacks and anxiety and ocd behaviors, none of which I had ever had before,ever
Feb. '09-MRSA cultures neg, but treated w. antibiotics-not better, got worse Mar.'09-still have skin sores, old ones not healing, new ones still appearing-skin thinning more, and developed fever, which lasted for 27 days, blood tests done for all auto-immune diseases, all normal or neg.
Apr.'09-referred to Dermatologist, who put me on zoloft and said I was having physical manifestations of stress. also put on prednisone for 10 days , and treated again with cipro, slight improvement on all symptoms for about 3 weeks.
That overall diagnosis,however never sat well with me, medical insurance off and on made it financially immpossible to continue seeking medical help-- same symptoms ongoing, no relief. learning how to 'cope' best I can
Dec.09-admitted to ER, severe abdominal pain, cause unknown, thought to be apendix, it was not, however, during the ct scan,a 12mm left adrenal adenoma was found, was told to follow up w/ dr.-a week later my primary dr reffered me to an endocrinologist,who ordered blood and urine tests, which i am troubled by, not by the dr, but by the lab tech who took my 24 urine & blood, not knowing the names of the tests ordered, which tubes to use, etc..., also, when my lab results did come in, they all state fasting as NO, when in fact I did fast, when I mentioned this and the 'lab tech' to the endo. he became defensive, even tho i stated no professional disrespect toward him, but wanted him to know my reservations, and i never did get an anser if fasting "no" instead of yes was a point of concern --
results did show abnormally low aldosterone-was told to come back in 3-6 months for follow-up ct scan
June2010- follow up ctscan shows no growth to adrenal adenoma but in additon a new 3mm lesion on left kidney. What can I expect the next step to be? And, why isnt my endo concerned with my symptoms that I am still suffering from?
 Dr.M.Aroon kamath - Thu Jun 24, 2010 12:02 pm

User avatar HI,
Definition of an adrenal 'incidentaloma' : an incidentally detected adrenal mass not suspected prior to the imaging procedure which led to its discovery.

The prevalence of incidentally detected adrenal masses appears to increase with age.Their peak prevalence is between 6th and 7th decades(3–7 %) and has been noted to be higher in patients with features of the metabolic syndrome(obesity, arterial hypertension, insulin resistance) when compared to the rest of the population.

On detection of an adrenal incidentaloma, one needs to answer the following questions:
1.Is it really an adrenal or extra-adrenal mass?
2.Is it possible that it is a metastasis from an unknown or known primary tumor?
3.Is it hormonally active(secreting)?
4.Is it possible that it is an adrenocortical carcinoma?

If it is fairly certain that it is an adrenal 'incidentaloma', the following assume importance:
- size of the lesion,
- whether it is secreting any hormones (functioning) or non-secreting (non-functioning).
- if functioning, which hormone is being secreted?

If an incidentaloma is functioning, depending on the hormone secreted, various confirmatory tests will be needed. This aspect will not be discussed further here.

Generally speaking,
- larger the lesion, higher are the chances of it being malignant,
- for most secreting tumors, surgery is the right option.

Therfore, all tumors > 6 cm should be surgically removed. All hormonally active incidentalomas must also be surgically removed to prevent serious morbidity. This approach is well accepted for pheochromocytomas and Conn's adenomas. Controversies exist as to whether all patients with subclinical Cushing's syndrome benefit from adrenal surgery, as progress of subclinical disease to overt Cushing´s syndrome seems to occur only in a minority of cases.

Role of FNA:
In patients with adrenal incidentaloma and no history of malignancy, FNA has not proven to be beneficial, as cytologic differentiation between benign and malignant adrenal tumors is difficult.

Follow-up: of patients with nonfunctional adrenal mass shows that only 5-30% of masses increase in size.Follow up imaging study is recommended 6 – 12 month after initial evaluation. Further follow up studies are not considered necessary, since tumor growth becomes “stable” by that time.

If definite tumor growth is seen on follow-up imaging, surgical removal of the tumor is recommended. Surgical removal of suspicious tumors >3 cm or even 2 cm has been recommended by some.

The advancements in imaging techniques (CT and MRI) in characterization of adrenal masses is expected to restrict FNA to a very few indications.

Following a careful workup, it is now possible for the endocrine surgeons to be reasonably confident in their decision to operate or observe an adrenal incidentaloma in the majority of cases.

Surgery, if indicated, can be
- the traditional 'open' approach, or
- a laparoscopic approach((transabdominal or retroperitoneal).

The lesion in your kidney most likely is another incidentaloma (renal). As details regarding its details on imaging (solid or cystic etc) are not mentioned, i will refrain from discussing it further here. However,there have been reports in the literature of renal cell carcinomas metastasizing to the adrenals.

Best wishes!

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