Adrenal adenoma

Evaluate patients with adrenal adenomas for unilateral adrenalectomy. 

Inhalation of monomethylhydrazine was not carcinogenic in rats or dogs, but mice exposed at 2 ppm for 1 y exhibited an increased incidence of lung tumors, nasal adenomas, nasal polyps, nasal osteomas, hemangioma, and liver adenomas and carcinomas. Hamsters exposed at 2 or 5 ppm exhibited an increased incidence in nasal polyps, interstitial fibrosis of the kidney, and benign adrenal adenomas. An increase in nasal adenomas was seen in hamsters exposed at 5 ppm. 

ACTH-independent Cushing s syndrome is usually caused by adrenal adenomas and carcinomas. 

Adrenal adenoma Surgery, postoperative Ketoconazole (Nizoral) 200-mgtabs 200 mg once or twice a day 200-1,200 mg/day, divided twice a 1,600 mg/day divided... 

Long-term maintenance therapy for patients with discrete aldosterone-producing adrenal adenomas who are poor operative risks, or who decline surgery. 

Primary aldosteronism usually results from the excessive production of aldosterone by an adrenal adenoma. However, it may also result from abnormal secretion by hyperplastic glands or from a malignant tumor. The clinical findings of hypertension, weakness, and tetany are related to the continued renal loss of potassium, which leads to hypokalemia, alkalosis, and elevation of serum sodium concentrations. This syndrome can also be produced in disorders of adrenal steroid biosynthesis by excessive secretion of deoxycorticosterone, corticosterone, or 18-hydroxycorticosterone—all compounds with inherent mineralocorticoid activity. 

These conditions are associated with high renin and high aldosterone production. The hybrid corticosteroids 18-OHF, 18-oxo-F and 18-oxo-THF were isolated from the urine of a patient with adrenal adenoma by Ulick and coworkers [11]. These steroids were subsequently also shown to be dominant in GRA. Their formation in the latter condition was explained by Lifton and co-workers [51] with the discovery of a chimeric gene formed crossover of the 1 1//-hydroxylase (CYPllfil) and aldosterone synthase (CYP11B2) genes. 

Jeunemaitre X, Charru A, Pascoe L, Guyene TT, Aupetit-Faisant B, Shackleton CH, Scham-belan M, Plouin PF, Corvol P (1995) [Hyperaldosteronism sensitive to dexamethasone with adrenal adenoma. Clinical, biological and genetic study]. Presse Med 24 1243-1248... 

Because of its effects on the pituitary/adrenal system, ketoconazole has been used in the long-term control of hypercortisolism of either pituitary or adrenal origin (SED-12, 677). In seven patients with Cushing s disease and one with an adrenal adenoma, ketoconazole 600-800 mg/day for 3-13 months produced rapid persistent clinical improvement (585). Plasma dehydroepiandrosterone sulfate concentrations and urinary 17-ketosteroid and cortisol excretion fell soon after the start of treatment, and remained normal or nearly so throughout treatment. Urinary tetrahydro-ll-deoxycortisol excretion rose... 

ACTH-independent Cushing s syndrome shows increased cortisol, but the ACTH is not elevated but rather decreased due to negative feedback. It can be caused by exogenous administration of glucocorticoids or by adrenal adenoma, carcinoma or nodular hyperplasia. 

A 62-year-old hypertensive man with renal artery stenosis, an adrenal adenoma, peripheral artery disease, and an abdominal aortic aneurysm developed a hypertensive crisis with chest pain. He was treated with nitrates, heparin, aspirin, and nicardipine, which were afterwards replaced by diltiazem 200 mg/day, because of persistent chest pain. He developed atrioventricular block 2 hours after the second dose of diltiazem, and was successfully treated with a pacemaker. 

Primary hyperaldosteronism (adrenal adenoma or rarely, carcinoma)... 

Primary adrenal adenoma (Cushing s syndrome) Pituitary adenoma secreting ACTH (Cushing s disease) Exogenous cortisol therapy Excessive licorice ingestion Bartter s syndrome (defective renal CL reabsorption)... 

The remaining 18% of Cushing s syndrome cases are ACTH-independent and are almost equally divided between adrenal adenomas and adrenal carcinomas, with rare cases caused by micronodular or macronodular hyperplasia." The majority of adrenal cortex tumors are benign adenomas. Adrenal carcinoma is found more often in children than in adults with Cushing s syndrome. 

TABLE 74—5. Alternative Steroid Replacement Regimens in the Adrenal Adenoma Patient... 

Primary aldosteronism implies that the physiologic abnormality is within the adrenal cortex. The most common causes include a solitary adrenal adenoma (60%) or idiopathic adrenocortical hyperplasia (35% bilateral and 5% unilateral). Other rare causes include adrenal cortex carcinoma, primary adrenocortical hyperplasia, renin-responsive adrenocortical adenoma, and genetic mutations, such as in glucocorticoid-suppressible hyperaldosteronism. " " ... 

The diagnosis of hyperaldosteronism may be made in the hypokalacmic patient if the serum aldosterone level exceeds the upper limit of nomial or if the level is persistently inappropriate to the scrum potassium. In primary hyperaldosleronism. where the excess aldosterone arises from an adrenal adenoma, the levels of plasma renin will be low. 

As with other K+-sparing diuretics, spironolactone often is coadministered with thiazide or loop diuretics in the treatment of edema and hypertension. Such combinations result in increased mobilization of edema fluid while causing lesser perturbations of K+ homeostasis. Spironolactone is particularly useful in the treatment of primary hyperaldosteronism (adrenal adenomas or bilateral adrenal hyperplasia) and of refractory edema associated with secondary aldosteronism (cardiac failure, hepatic cirrhosis, nephrotic syndrome, and severe ascites). Spironolactone is considered the diuretic of choice in patients with hepatic cirrhosis. Added to standard therapy, spironolactone substantially reduces morbidity and mortality and ventricular arrhythmias in patients with heart failure. 

THERAPEUTIC USES Spironolactone often is coadministered with thiazide or loop diuretics in the treatment of edema and hypertension. Such combinations result in increased mobilization of edema fluid with lesser perturbations of K+ homeostasis. Spironolactone is particularly useful in the treatment of primary hyperaldosteronism (due either to adrenal adenomas or bilateral adrenal... 

---