Incidentaloma medical therapy

The mainstay of treatment for adrenal incidentaloma is surgery but pre-operative medical management is needed for functional masses. Peri-operative medical management of patients with sub-clinical Cushing’s syndrome includes glucocorticoid therapy during surgery. Such patients can safely undergo surgical resection of their tumor and have their cortisol levels measured post-operatively. Preoperative medical management of patients with pheochromocytoma includes preoperative treatment to control hypertension during surgery and hypotension after it. Three medical regimens for preoperative management of pheochromocytoma: Combined alpha and beta-adrenergic blockers, calcium channel blockers, and Metyrosine. Pre-operative medical management of patients with aldosteronoma include medical therapy with mineralocorticoid receptor antagonists should be reserved for those who are unable or unwilling to undergo surgery.

The mainstay of treatment for adrenal incidentaloma is surgery but preoperative medical management is needed for functional masses.

• There are two approaches to deal with cases of Cushing’s syndrome:^[1][2][3]
  • Patients do not require glucocorticoid therapy during surgery. Such patients can safely undergo surgical resection of their tumor and have their cortisol levels measured post-operatively.
  • This would provide an early evaluation of surgical success. Hydrocortisone may be given to the patient 30 mg in the morning and 10 mg in the afternoon until the result of the cortisol level becomes available.^[4]
  • Another approach would be to cover all patients with glucocorticoids peri-operatively.^[5]

• All patients undergoing surgery need preoperative treatment to control hypertension during surgery and hypotension after it.^[2][6]
• According to Endocrine Society’s 2014 clinical practice guidelines, there are three medical regimens for preoperative management of pheochromocytoma:^[1][2]
  • Combined alpha and beta-adrenergic blockers
  • Calcium channel blockers
  • Metyrosine

• It is used to counteract hypertension and the beta-1 adrenoceptor antagonist atenolol to reduce cardiac output. They can block the sudden release of adrenaline during surgical stress and prevent hypertensive crisis. The patient is ready for surgery after 10 to 14 days of initiation of alpha-adrenergic blockade. Patients should take high sodium diet to prevent orthostatic hypotension due to alpha blockers. After adequate alpha-adrenergic blockade has been achieved, a beta-adrenergic blocker is initiated 3 days before surgery.^[7]

Beta-adrenergic blocker

• It should never be started first because unopposed alpha-adrenergic receptor stimulation can lead to the brisk increase in blood pressure. It should be used with caution due to the risk of heart failure, pulmonary edema, and asthma.^[8]

• It is used to control blood pressure pre-operatively and an intravenous injection is given intra-operatively.
• Its main use is controlling blood pressure in case of failed alpha and beta blockers regimen or unaccepted side effects in that regimen.^[9]

• It is the last medical line of treatment. It inhibits catecholamine synthesis.
• It is used in case of failure of other medical lines of treatment or in patients who cannot tolerate them.
• Clinicians use combined treatment in difficult cases and if radiofrequency ablation for metastatic foci will be used.
•  Side effects of Metyrosine include:^[10]
  • Crystalluria
  • Extrapyramidal manifestations
  • High cost.

• Medical therapy with mineralocorticoid receptor antagonists should be reserved for those who are unable or unwilling to undergo surgery.^[11][12][2]
  • Adrenalectomy in patients with a documented unilateral source of primary aldosteronism is more cost effective compared with lifelong medical therapy.
  • Laparoscopic adrenalectomy compared to an open procedure is associated with a shorter hospital stay, fewer complications, and faster recovery.
  • Resection of the adrenal tumor will result in resolution of hypokalemia and improvement in hypertension in almost all patients.

• Postoperative management in patients with primary hyperaldosteronism includes:^[13]
  • Potassium supplementation and mineralocorticoid receptor antagonists should be stopped post-operatively with close monitoring of serum potassium.
  • A temporary state of hypoaldosteronism may also develop in some patients with primary aldosteronism post-operatively and can be managed by increasing salt intake.

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