Locally Advanced

Wesley A. Mayer, MD, Associate Professor of Medicine at Baylor College of Medicine in Houston, Texas, discusses how urologists should medically assess and surgically manage adrenal masses. He begins by briefly going over his sources, including the 2016 European Society of Endocrinology Clinical Practice Guideline, the 2011 Canadian Urology Association Guidelines, the 2009 American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons Guidelines, material from UpToDate, and the work of Alexander Kutikov, MD, FACS. He highlights the fact that there is no AUA guideline on adrenal masses, as well as very little new guidance in this space. Dr. Mayer suggests that urologists should be more involved in managing adrenal masses since they are surgical experts of the retroperitoneum, familiar with the anatomy and pathophysiology of the kidneys and adrenal gland, and experts at minimally invasive surgery. He then defines the adrenal mass as a >1 cm lesion that can arise from the medulla or cortex. He explains that the majority are discovered incidentally and are called “adrenal incidentaloma,” and advances in modern imaging technology have significantly increased their prevalence. Most adrenal masses are benign lesions but some are not, and Dr. Mayer lists three important questions a urologist should ask to determine risk when confronted with a mass, including whether there are characteristics suggestive of a malignancy, whether the mass is hormonally active, and whether the patient has a history of malignancy. He then summarizes key points in how to evaluate adrenal masses radiologically and metabolically, and discusses when biopsy is necessary. Dr. Mayer follows this with an overview of surgical management, noting that laparoscopic adrenalectomy is standard of care for most masses and open adrenalectomy should be performed if adrenal cortical carcinoma is suspected. He also shows a video of an adrenalectomy for pheochromocytoma. Dr. Mayer concludes by explaining that follow-up is important since some masses will convert to being hormonally active and/or will have concerning growth characteristics.