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Adrenal glands – what they do and what can go wrong?

If an adult undergoes a computer tomography (CT scan) as part of investigations after trauma or during assessment for abdominal pain or tumour, there is an overall 1:20 chance that the scan will pick up an unexpected (small) tumour in one of the adrenal glands


his risk is minimal in young patients (under 30 years) and reaches 1:10 by 70-80 years

of age. Tis is the most common scenario, which leads one to ask: what are the adrenal glands? Te adrenal glands are an important

part of the endocrine system, which consists of a multitude of small organs that release chemicals (hormones) into the bloodstream that affect the func- tion of other tissues in the body. Te adrenal hormones contribute to the maintenance of normal blood pressure and sugar levels. Furthermore, the normal reaction of the body to extreme stress relies on the secretion of adren- alin hormones as part of the ‘fight or fly’ response.

Tese glands were first described in

the 16th century but understanding their function emerged in the early 20st century. Adrenalin was purified in the early 1900s and the discovery of the structure and biological effects of the steroid hormones from the adrenal cortex led to a Nobel Prize in 1950. Similar to many other endocrine diseases, adrenal can be affected by too little or too much hormonal secretion. A deficit of adrenal function bears

the name of the 19th-century London physician Tomas Addison. In such patients, most commonly, the adrenal glands had been destroyed by the immune system. Teir daily survival is dependent on regular intake of steroid-replacement tablets and this makes patients particularly suscep- tible to a poor stress response during other acute illnesses (such as infec- tions, an issue increasingly relevant during the ongoing pandemic). Every year in the UK there are,

Radu Mihai

at most, 1,000 adrenal operations performed, demonstrating that tumours of the adrenal glands needing surgical treatment are relatively uncommon. Historically, many such operations were there- fore performed in hospitals with minimal or no previous experience in managing such patients. Tis situ- ation is expected to change in the coming years as a process will be put in motion to allow these operations to take place only in hospitals doing at

an estimated one to two patients per million population per year. Radical surgery, frequently involving removal of other organs together with the adrenal tumour (such as kidney and/ or spleen), is the only effective treat- ment for this disease. Complex preop- erative assessment for hormonal activity and radiological appearance of the tumour, extensive operations involving more specialty surgeons and careful oncological treatment after the operation are vital to a favour- able outcome and are only available in large tertiary referral centres. Te outcomes of operations on over 60 patients in Oxford in recent years has just been published and we are keen to expand on this experience. Phaeochromocytomas


least six cases per year. Further, care will be centralised in more complex cases in units doing at least 12 cases per year and having a functional multi- disciplinary environment that comple- ments surgical expertise with medical endocrinology, radiology and oncology expertise. While such changes are yet to be implemented, each patient referred for adrenal surgery should feel empowered to enquire about the annual workload of the local surgical team and to ask referral to a regional unit with appropriate expertise. In this context, what patients

should really benefit from travelling to a regional unit with expertise in adrenal surgery? Adrenal cancer is a very aggressive and exceedingly rare disease, with

tumour-producing adrenaline-type hormones) raise specific challenges in order to avoid/manage the large changes in blood pressure that can occur during the operation and there- fore the experience of the anaesthetic team is maybe more important than the surgical ability of the individual surgeon. Currently, adrenal surgery for phaeochromocytomas represents over a third of the cases operated yearly in Oxford. Because many patients are investi-

gated to ascertain the possible genetic cause of their disease, they can find support and information from a very active patients’ support group focused on

familial endocrine tumours

( Mr Radu Mihai explains,

“Troughout the past 15 years, I’ve encouraged communication with many endocrinologists in hospitals in the South of England that led to constant referrals towards our Oxford

unit, building up the current annual workload of 100 adrenal operations per year. I’m particularly keen to facil- itate transfer to our unit of patients deemed high risk or deemed to have advanced local disease that others might consider inoperable because of tumour extension in the large blood vessels (renal vein, vena cava). Te entire spectrum of adrenal surgery is available in Oxford, starting with ‘key-hole’ operations, either from the front (laparoscopic) or from the back (retroperitoneoscopic), extending to open adrenal surgery for aggres- sive tumours and complex abdom- inal/cardiac operations for the most advanced cases.” In summary, many adults

might harbour a small adrenal tumour but the majority of them are small and pose no threat to health. When such tumours produce excess amounts of hormones they can have a negative impact on health and need assessment and treatment at in institutions that can offer a large spectrum of multidisciplinary input.

As telemedicine has become increasingly accessible during the Covid pandemic, Mr Radu Mihai will be very happy to advise patients remotely and facilitate their decisions regarding future (surgical) treatment. Visit

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