Adrenal Tumors: Therapy

2023 Author: Wallace Forman | [email protected]. Last modified: 2023-05-24 12:25

Adrenal tumors: therapy

Treatment of adrenal tumors primarily depends on whether the tumor is hormone-active or hormone-inactive. In the case of hormone-active tumors, surgical removal is the main focus, as is the case with hormone-inactive tumors that may be malignant. Tumor size, tissue density and the patient's request are criteria for removal.

The decision on treatment is made jointly by experts from various medical specialties.

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• What treatment options are there?
• How is the operation performed?
• What happens after the operation?
• Whom can I ask?
• How are the costs going to be covered?

What treatment options are there?

In the case of hormone-active tumors (and those with "mild" hormone overproduction), surgical therapy is the focus. The tumor is removed along with the affected adrenal gland.

Hormone-inactive tumors themselves do not require therapy. The tumor size, its tissue density and the wishes of the patient are decisive for the further procedure. The tumor size can be precisely determined using CT and MRI and checked in follow-up examinations. The tissue density is also determined by CT or MRI (Houndsfield units, see Adrenal Tumors Diagnosis).

• Hormone inactive tumors between one and three centimeters in size are almost never malignant. Their removal is only necessary in the case of documented rapid increase in size.
• For adrenal tumors between three and five centimeters in sizeif there is a relative indication for surgery (gray area, ie an operation is not absolutely necessary, but those affected may benefit from it). Malignancy is rare in this tumor group, but has been described in individual cases. If you decide against the operation after a careful discussion with the patient, regular follow-up checks must be carried out. CT or MRI three, nine and 18 months after the initial diagnosis are suitable for this. If the tumor increases rapidly in size or if there are other indirect indications of malignancy (inhomogeneity, Houndsfield units over ten and higher), surgical therapy must always be carried out. In addition, hormones should be tested once a year for the first four years (with appropriate function tests).
• Tumors over six centimeters in diameter should be treated surgically. Above this size, the chance of maliciousness increases by leaps and bounds.

In principle, the following applies: The aim of surgical therapy is the timely and complete removal of a malignant tumor, at the same time "unnecessary" adrenal removal should be avoided in the case of benign disease. Although minor, any possible complications of the procedure must also be considered prior to any adrenal surgery.

More on the topic: Adrenal Tumors Forms & Symptoms

How is the operation performed?

If you decide to have an operation, the tumor is removed along with the affected adrenal gland.

Regardless of whether the adrenal gland is hormone-active or hormone-inactive: If there is no suspicion that the tumor is malignant and if it is less than six centimeters in size, the operation is usually performed endoscopically from behind (access via the back) or from the side in front ("Keyhole Surgery"). This means that several small incisions are made through which the surgical instruments are inserted. Only small scars remain and the operation is associated with less pain overall.

Pheochromocytoma

Before a pheochromocytoma can be operated on, a special blood pressure medication (alpha blocker) must be taken for a period of one to two weeks, which counteracts the effects of noradrenaline and adrenaline on the blood vessels. By manipulating the tumor during the operation, there is a risk of a sudden release of the two hormones and thus of life-threatening blood pressure crises; Appropriate pre-treatment should prevent such incidents. Depending on the size, pheochromocytomas are removed endoscopically. For a malignant pheochromocytoma, therapy depends on the stage of the tumor. If removal is possible and sensible (no distant metastases), an open surgical method is chosen. Depending on the tumor stage and any existing metastases, radioiodine therapy or new drug therapy forms are available.

Conn adenoma

Before the operation, the blood pressure must be brought under control with medication and the potassium deficiency compensated (with so-called aldosterone antagonists). Aldosterone-producing Conn adenomas are usually very small and are removed endoscopically. Removing it can at least improve chronic high blood pressure. If necessary, lifelong drug therapy is also necessary. In any case, the operation can significantly improve the quality of life of those affected.

Cushing's adenoma

A tumor of the adrenal gland that causes overproduction of cortisol (Cushing's syndrome) is removed endoscopically. After the operation, a so-called cortisol withdrawal syndrome can occur: The remaining adrenal gland does not initially manage to maintain the normal cortisol level - this is why cortisol must be taken in the form of tablets. After gradually reducing the dose, the remaining adrenal gland resumes normal hormone production within three to six months.

Special case: subclinical Cushing's syndrome

The so-called subclinical Cushing's syndrome is a special case: A tumor of the adrenal gland is discovered by chance (as an incidentaloma), which shows a slightly increased overproduction of cortisol in the further investigation. The typical clinical symptoms of Cushing's syndrome are missing. There are no standardized treatment recommendations for this. The decision for further steps is made individually and depends, among other things, on possible concomitant illnesses as well as the patient's state of health and age. Most of the time, the patients benefit from an operation.

Malignant tumor or adrenal carcinoma

Any tumor of the adrenal cortex that is classified as possibly malignant based on the examination results (CT or MRI) is surgically removed. These include tumors that

• are six inches in diameter or larger,
• meet other radiological criteria that speak for a carcinoma (e.g. irregular borders, inhomogeneity; Houndsfield unit over ten),
• grow by more than one centimeter or 20 percent within a year,
• Produce sex hormones,
• produce several different groups of adrenal hormones (e.g. sex hormones and cortisol at the same time). Computed tomography

Open surgery through the abdomen is usually performed for these tumors.

In the case of a malignant tumor, all of the tumor tissue must be removed in order to have the greatest possible chance of healing. The adjacent lymph nodes must also be removed. Depending on the extent of the tumor and in the absence of settlements in other organs (distant metastases), neighboring organs such as kidneys, liver or stomach must also be removed in order to increase the chances of recovery. Complete healing is not possible in advanced tumor stages with distant metastases. Whether an operation makes sense in these cases is decided individually.

In addition to surgery, drug treatments are given to prevent possible tumor recurrence. This primarily includes taking the active ingredient Mitotane, a drug that inhibits cell division and the formation of hormones in the adrenal gland and is used specifically in the treatment of adrenal tumors. Radiation can also be used after the operation.

Mitotane is also the drug of choice when the adrenal tumor cannot be surgically removed. It can stop the tumor from growing or even cause it to shrink and thus increase the life expectancy of those affected. It is often given in combination with chemotherapy.

What happens after the operation?

Annual controls of hormone production are recommended after the surgical removal of benign, hormone-active tumors. Pheochromocytoma, for example, can recur years after the operation.

For adrenal cancer that has been completely surgically removed, check-ups are recommended every three months in order to detect possible recurrence of the tumor early. This includes imaging examinations such as CT or MRI as well as the determination of the hormone status and any tumor markers in the blood. After two years of tumor-free treatment, the intervals between check-ups can be extended to twice a year.

Whom can I ask?

Since the adrenal glands are one of the main endocrine glands in the body, the primary contact person should be a specialist in clinical endocrinology. In further diagnostics and therapy planning, specialists from the fields of surgery (surgical endocrinology) are called in together with specialists from radiology, nuclear medicine and / or oncology. The decision for treatment for adrenal tumors is usually made in so-called tumor boards, ie in a kind of conference in which experts from various disciplines consult and decide together according to the latest state of knowledge.

How are the costs going to be covered?

All necessary and appropriate diagnostic measures are taken over by the health insurance carriers. Basically, your doctor or the outpatient clinic will settle accounts directly with your health insurance provider. With certain health insurance providers, however, you may have to pay a deductible (BVAEB, SVS, SVS, BVAEB). However, you can also use a doctor of your choice (ie doctor without a health insurance contract) or a private outpatient clinic. For certain examinations (e.g. MRI), a doctor's approval may be required. For more information, see Costs and Deductibles. For information on the respective provisions, please contact your health insurance provider, which you can find on the social security website.