**5.3 Androgen- and estrogen-producing tumors**

In cases of congenital adrenal hyperplasia due to a 21-hydroxylase deficiency, it is rather common to find adrenal masses, either uni- or bilateral ones, presumably due to excessive chronic stimulation of adrenals by ACTH [1].

Sex-hormone-producing adrenal adenomas are very rare. Androgen-producing carcinomas are also uncommon. Nevertheless, patients generally manifest some virilization, which makes it unlikely for such tumors to be related to adrenal incidentalomas. Thus, the routine testosterone and estradiol dosage are not recommended for patients with adrenocortical incidentalomas who present trace of

### **Figure 3.**

*Basic Principles and Practice in Surgery*

hemodynamic crisis, and death [12].

**5.2 Aldosterone-producing tumors**

are almost hyperaldosteronism pathognomonic [1].

a perioperative coverage of glucocorticoid due to the risk of adrenal insufficiency,

*An algorithm for investigation of Cushing's syndrome in adrenal incidentalomas. Dexa, dexamethasone; SC, serum cortisol; UFC, urine-free cortisol; ACTH, adrenocorticotropic hormone. \*At least two measurements.*

Also known as aldosteronomas, they are rare (less than 1% of cases), and their characteristic manifestation is systemic arterial hypertension associated with hypokalemia. Yet primary normocalcemic hyperaldosteronism is common (20–50% of cases) [1, 12]. For that reason, as most patients suffering from primary aldosteronism do not suffer from hypocalcemia, all patients suffering from hypertension and adrenal incidentaloma should be assessed through measurements of their aldosterone plasmatic concentration and plasma renin

Initial endocrine investigation in such cases consists of dosing the levels of plasma aldosterone and plasma renin activity. In case the ratio between them is <27, the existence of hyperaldosteronism is virtually excluded. Other authors use further landmarks (between 20 and 30) to establish diagnosis as abnormal. Values >40–50

It is important to mention that if the laboratory can only assess the renin direct dosage (other than the plasma renin activity), the renin value must be divided by 12, so that the actual value of plasma renin activity is established, which will eventually be the one used for the ratio calculation. If the ratio is lower than 20, it can refute diagnosis. In case it is between 20 and 30, it indicates a likely diagnosis. Then, if it exceeds 30, with aldosterone dosage higher than 15 ng/dl, positive tracing should be considered and investigation should continue through tests for confirmation [2]. In patients with spontaneous hypokalemia, plasma renin below detection

scenario of patients with subclinical or classic Cushing's syndrome [12].

Weight loss, improvement of hypertension, glycemic control, and normalization of bone renewal markers are frequently found in the post unilateral adrenalectomy

**48**

activity [12].

**Figure 2.**

*Algorithm for investigation of hyperaldosteronism in adrenal incidentalomas. \*Most commonly used confirmatory tests: oral sodium loading test and intravenous saline infusion test. # In patients with spontaneous hypokalemia, plasma renin below detection levels plus plasma aldosterone > 20 ng/dl, it is suggested that there is no need for further confirmatory testing.*

virilization [1]. For individuals that present such virilization or high concentrations of androgens, adrenalectomy may be indicated for controlling of hormones.

Estrogen-producing tumors are rare and they are generally malignant. In men, it may manifest through feminization with gynecomastia, decrease in libido, atrophy of testicles, whereas in women, it could manifest through breast sensitivity and bleedings [12]. In such cases, adrenalectomy may also be indicated.
