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Difficulty: HardBreast and Endocrine Surgery

Match each clinical presentation of an adrenal mass with the most appropriate specific perioperative or surgical management step.

  • A 45-year-old patient with episodic palpitations, diaphoresis, elevated plasma fractionated metanephrines, and a 4.5-cm adrenal mass.Initiation of non-selective alpha-adrenergic blockade for 10-14 days followed by beta-adrenergic blockade prior to laparoscopic adrenalectomy.
  • A 38-year-old patient with resistant hypertension, muscle cramps, low serum potassium, high aldosterone-to-renin ratio, and a 2-cm unilateral adrenal mass.Preoperative optimization with an aldosterone receptor antagonist and potassium supplementation prior to laparoscopic adrenalectomy.
  • A 50-year-old patient with central adiposity, proximal muscle weakness, elevated 24-hour urine free cortisol, suppressed ACTH, and a 3.5-cm adrenal mass.Laparoscopic adrenalectomy with administration of intraoperative and postoperative stress-dose glucocorticoids to prevent acute Addisonian crisis.
  • A 55-year-old patient with abdominal pain, a rapidly enlarging 9-cm heterogeneous adrenal mass with irregular margins on CT, and elevated serum DHEA-S.Open en bloc adrenalectomy with potential resection of adjacent involved structures, strictly avoiding preoperative percutaneous biopsy.

Answer

Pheochromocytoma pairs with alpha/beta blockade; Conn syndrome pairs with aldosterone antagonists; Adrenal Cushing syndrome pairs with postoperative glucocorticoids; Adrenocortical carcinoma pairs with open en bloc resection.
Each adrenal pathology requires distinct surgical planning. Pheochromocytoma requires sequential alpha then beta blockade to prevent intraoperative hypertensive crisis. Primary hyperaldosteronism requires potassium repletion and mineralocorticoid receptor blockade. Adrenal Cushing syndrome causes contralateral gland atrophy, necessitating perioperative stress-dose glucocorticoids to prevent acute adrenal insufficiency after tumor removal. Large, suspicious masses (adrenocortical carcinoma) require open en bloc resection to avoid capsular rupture and tumor seeding, which are risks with laparoscopic approaches and percutaneous biopsies.

Step-by-Step Solution

1
Analyze the clinical, laboratory, and imaging findings for each adrenal mass presentation to establish the underlying diagnosis.
Identified diagnoses are pheochromocytoma, primary hyperaldosteronism, adrenal Cushing syndrome, and adrenocortical carcinoma.
Each type of functional or malignant adrenal tumor has distinct physiologic consequences that dictate perioperative management.
2
Determine the specific pathophysiologic risks associated with the surgical removal of each tumor type.
Pheochromocytoma risks hypertensive crisis; Conn syndrome involves potassium wasting and hypertension; Cushing syndrome risks postoperative adrenal crisis due to HPA axis suppression; Adrenocortical carcinoma risks tumor spillage and local invasion.
Surgical and perioperative strategies are tailored to mitigate these life-threatening complications.
3
Match the diagnosis with the standard-of-care surgical and perioperative intervention.
Correct pairings are made based on surgical guidelines for endocrine pathology.
Ensures adherence to best practices in endocrine surgery and patient safety.

Key Concept

Perioperative and surgical management of functioning and malignant adrenal tumors
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Topics

Breast and Endocrine Surgery

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