General Surgery Rotation

• Less common benign masses include myelolipoma/lipoma, ganglioneuroma, epithelial cyst, and pseudocyst
• Nearly 4% of abdominal CT scans obtained for another indication demonstrate an incidental adrenal mass
• Adrenal tumors can also be detected clinically due to manifestations of tumor hormone production
• Of all adrenal masses, 80% are nonfunctional adenomas, while 15% are functional with laboratory evidence of hormonal overproduction
• Functional tumors include pheochromocytomas, aldosteronoma, and cortisol-producing adenomas. In patients with a previous or present history of malignancy, adrenal metastasis should be considered in the differential

Laboratories

• Plasma fractionated metanephrines or 24-hour urine metanephrines—must rule out pheochromocytoma for any adrenal mass
• Serum potassium and aldosterone and plasma renin activity
• 24-hour urinary-free cortisol or dexamethasone suppression test
• DHEA-S—high levels can be associated with ACC; virilization is the clinical manifestation of androgen overproduction
• CT scan - size > 4 cm
• MRI

Treatment:

• Adrenal tumors with evidence of hormone production or suspicion of ACC should be considered for adrenalectomy
• Prognosis for ACC is dependent on treatment at an early stage and complete surgical excision with negative margins
• Laparoscopic adrenalectomy is NOT recommended for ACC given higher local recurrence rates due to positive or close margins
• Complete resection often requires en bloc resection of kidney, spleen, pancreas, liver, or IVC for negative margins
• Overall prognosis remains poor with overall 5-year survival of 25%

• Addison's disease (adrenocortical insufficiency) - adrenal gland destruction causing lack of cortisol and aldosterone secretion usually autoimmune. (↓ cortisol)
• Hypothyroidism: Cold and heat intolerance, fatigue, constipation, depression, weight gain, bradycardia
• Diabetes mellitus: fatigue, weight loss, polyuria, polydipsia, polyphagia
• Pituitary insufficiency
• Hypercalcemia
• Chronic renal failure
• Hepatic failure

Laboratory testing: 

• Complete blood count - anemia
• Erythrocyte sedimentation rate - inflammatory state
• Chemistry panel - liver disease, renal failure, protein malnutrition
• Thyroid function tests - hypothyroidism
• Human immunodeficiency virus antibodies - if not previously tested
• Pregnancy test, if indicated

Less commonly indicated

• Chest radiography - adenopathy
• Tuberculin skin test
• Electrocardiography - CHF, arrhythmia
• Pulmonary function tests - COPD, cancer
• Toxicology screen - substance abuse
• Lyme titers - chronic Lyme disease
• Rapid plasma reagin - syphilis infection
• Brain magnetic resonance imaging - Multiple sclerosis
• Echocardiography - valvular heart disease, CHF
• Specialized blood testing (e.g., ferritin, iron, vitamin B12, and folate levels; iron-binding capacity; direct antiglobulin test)

• Cold and heat intolerance, fatigue, constipation, depression, weight gain, bradycardia
• Labs: TSH- elevated in primary disease. Low T4 (↑ TSH and ↓ Free T4)
• Hashimoto’s: Antithyroid peroxidase, antithyroglobulin antibodies

Hyperthyroidism (see below) - heat intolerance, palpitations, sweating, weight loss, tremor, anxiety, tachycardia

• Graves (autoimmune) - most common cause - diffuse goiter with a bruit, exophthalmos, pretibial myxedema
• Thyroid storm- Fever, tachycardia, delirium
• Toxic adenoma, thyroiditis, pregnancy, amiodarone

Diagnosis:

• TSH (best test): Decreased in primary disease (↓ TSH  and ↑ Free T4), elevated in secondary disease (↑ TSH  and ↑ Free T4)
• Thyroid radioactive iodine uptake:
  • Graves: Diffusely high uptake
  • Toxic multinodular: Discrete areas of high uptake

Antibodies (Graves): Anti-thyrotropin antibodies (anti-TSH receptor antibodies)

Treatment:

• Beta-blockers (symptomatic), methimazole/propylthiouracil, radioactive iodine, thyroidectomy
• Thyroid storm- prompt beta blockers, hydrocortisone, methimazole/propylthiouracil, iodine
• Thyroidectomy- most likely complication is recurrent laryngeal nerve (hoarseness)

Pheochromocytoma - recurrent headaches, HTN, sweating, palpitations

• Adrenal neoplasm - catecholamine secreting adrenal tumor - secretes norepinephrine and epinephrine autonomously and intermittently
• Recurrent headaches, HTN, sweating, palpitations.

Diagnosis:

• 24-hour catecholamines including metabolites (metanephrine and vanillylmandelic acid)
• MRI or CT of the abdomen to visualize tumor

Treatment:

• Resect tumor - complete adrenalectomy
• Medical treatment preoperative: Alpha blocker (phenoxybenzamine)

Most often papillary carcinoma (80%) - think papillary is "popular"

2. Follicular carcinoma: 10%
3. Medullary carcinoma: 5%
4. Hürthle cell carcinoma: 4%
5. Anaplastic/undifferentiated carcinoma: 1% to 2%

Diagnostic studies:

• Ultrasound is the best initial screen followed by a thyroid uptake scan. Usually normal thyroid function.
• Microcalcifications, hypoechogenicity, a solid cold nodule, irregular nodule margins, chaotic intranodular vasculature, and a nodule that is more tall than wide.
• Fine needle biopsy for definitive diagnosis (all lesions >1 cm should be biopsied)
• TSH, calcium level, CXR

Treatment: Surgical resection

• Surgical resection with chemotherapy and external beam radiation reserved for anaplastic thyroid cancer.

Evaluation:

• U/S—solid or cystic nodule
• Fine Needle Aspirate (FNA) -> cytology 123 I scintiscan (hot or cold nodule)
  • Hot—Increased 123 I uptake = functioning/ hyperfunctioning nodule (non-cancerous) 
  • Cold—Decreased 123 I uptake = nonfunctioning nodule (cancerous) 

History:

• Neck radiation
• Family history (thyroid cancer, MEN-II)
• Young age (especially children)
• Male > female

Signs:

• Single nodule
• Cold nodule
• Increased calcitonin levels
• Lymphadenopathy
• Hard, immobile nodule

Symptoms:

• Voice change (vocal cord paralysis)
• Dysphagia
• Discomfort (in the neck)
• Rapid enlargement

• Parkinson’s disease
• Wilson’s disease
• Essential tremor—only if severe: rest <postural and action

Postural and Action (Terminal) Tremors

• Physiologic tremor
• Exaggerated physiologic tremor (these factors can also aggravate other forms of tremor)
  • Stress, fatigue, anxiety, emotion
  • Endocrine: hypoglycemia, thyrotoxicosis, pheochromocytoma, adrenocorticosteroids
  • Drugs and toxins: b-agonists, dopamine agonists, amphetamines, lithium, tricyclic antidepressants, neuroleptics, theophylline, caffeine, valproic acid, alcohol withdrawal, mercury (Hatter’s shakes), lead, arsenic, others
• Essential tremor (familial or sporadic)
• Primary writing tremor
• With other CNS disorders
  • Parkinson’s disease
  • Other akinetic-rigid syndromes
  • Idiopathic dystonia, including focal dystonias
• With peripheral neuropathy
  • Charcot-Marie-Tooth syndrome (controversial whether to call this the Roussy-Levy syndrome)
  • Variety of other peripheral neuropathies (especially dysgammaglobulinemia)
• Cerebellar tremor

Kinetic (Intention) Tremor

• Disease of cerebellar outflow (dentate nucleus and superior cerebellar peduncle): multiple sclerosis, trauma, tumor, vascular disease, Wilson’s acquired hepatocerebral degeneration, drugs, toxins (e.g., mercury), others.

Miscellaneous Rhythmical Movement Disorders

• Psychogenic tremor
• Orthostatic tremor
• Rhythmical movements in dystonia (dystonic tremor)
• Rhythmical myoclonus (segmental myoclonus—e.g., palatal or branchial myoclonus, spinal myoclonus, limb myorhythmia)
• Oscillatory myoclonus
• Asterixis
• Clonus
• Hereditary chin quivering
• Head bobbing with third ventricular cysts
• Nystagmus