Our patient is a 56-year-old man with a known right adrenal tumor diagnosed 10 years ago. Nothing was done about it at the time. He did not have the required follow up. In retrospect, he should have had adrenal surgery 10 years ago.
He lives in Hongkong, and was now suffering from heart palpitations, pre-diabetes, hyperlipidemia, tremors, excessive sweating, panic attack symptoms, and dizziness. His catecholamines, normetanephrines and metanephrines were all very high (more than 10x normal).
He was a textbook case of pheochromocytoma.
He contacted us at the Carling Adrenal Center, and within days was on a flight from Hongkong to Tampa. His endocrinologist locally had already started him on a medication called alpha-blocker, so he was immediately ready for surgery. He had seen the most experienced adrenal surgeon in Hongkong. Unfortunately, the surgeon only performed the operation through the belly.
The patient had a mini back scope adrenalectomy (MBSA) which took 26 minutes. Can you imagine traveling across the planet for a 26-minute operation? Well trust me... It’s a lot better than traveling 20 minutes to the hospital down the street to have an eight-hour long operation involving a robot and with complications (or worse).
The patient had the best operation for pheochromocytoma.
Fortunately, the patient made the trip into a little bit of a mini vacation and will enjoy the beautiful spring in Florida and a trip to visit his family in the Northeast prior to heading back to Hongkong. We were all honored to take care of him and get him cured of his pheochromocytoma!
Every week I see multiple patients who clearly have had their adrenal tumor disease for years and decades. The disease has either not been diagnosed at all or just managed with ineffective medications.
The patient is a very sweet 82-year-old man who had been suffering with Conn’s syndrome or primary hyperaldosteronism for at least 25 years. When he was younger, he developed high blood pressure which he'd been managing with five different blood pressure medications and extra potassium for decades.
We were able to track down a CT scan he had almost 20 years ago and, no surprise, the left adrenal tumor was present back then. His lab test clearly showed his aldosterone levels to be very high and his renin levels to be low. It's obvious what was going on... This patient has had primary hyperaldosteronism due to a left aldosterone-producing tumor.
He was treated with one pill after another until a smart endocrinologist figured out what was going on. Unfortunately, he had already developed many complications from primary hyperaldosteronism. He had a stroke and has stage 3 chronic kidney disease (CKD). If he would've had surgery 20 years ago, this could easily have been prevented.
The adrenal adenoma was removed by a 24-minute Mini Back Scope Adrenalectomy (MBSA).
The photo shows the pathology of the 11 mm aldosterone producing adrenal adenoma.
He will benefit greatly from having his aldosterone levels normalized.
April 8 is Cushing's Disease Awareness Day!
In recognition, we are following up with a young 22-year-old UCLA student who underwent a bilateral adrenalectomy (BLA) because of “failed” Cushing’s Disease about 6 months ago.
Overall, she has done tremendously well since surgery. Watch the full Q&A to hear her discuss her long journey with Cushing's Disease, her surgery experience and her new and improved life.
The first-line treatment for Cushing’s disease is pituitary surgery to remove the tumor. When pituitary surgery works (70%), it is great! However, about 1/3 will never be cured in the first place or the tumor grows back (recurrence). This is “failed” Cushing’s Disease. Don’t despair! There are other treatment options.
In these patients, removing all cortisol-producing cells (total bilateral adrenalectomy) is often the best option. The goal is to remove all cells of the adrenal glands, which overproduce the toxic levels of cortisol.
The Mini-Back Scope Operation (MBSA) is the best adrenal operation for “failed” ACTH-dependent Cushing’s disease. Do not go through the belly to get to the adrenal glands!
Today's interesting case is an update from one of our favorite recent patients! Sara, a pregnant adrenal pheochromocytoma patient, underwent a mini back scope adrenalectomy (MBSA) with Dr. Carling a few months ago. Learn more about the MBSA procedure here: https://www.adrenal.com/adrena.../mini-scope-adrenal-surgery
She then sat down with us for a Q&A about her diagnosis, how she chose the Carling Adrenal Center, her surgery experience, her recovery and more.
Our entire team was so excited for Sara and requested an update from her when the baby was born, and she was kind enough to send us this halfway update!
"Since July/August is still a ways off, I thought a halfway there pregnancy update might be appreciated! We had our 20 week gross anatomy scan last Friday and baby appears healthy and is growing and developing normally. He or she even gave us a thumbs up (see ultrasound)! All my providers continue to be so impressed with how things turned out and Dr. Carling’s minimally invasive strategy to remove my adrenal tumor. Those who weren’t already aware of him have said they are sticking his name in their back pocket for any future adrenal patients needing surgery they may encounter."
We can't wait to hear from Sara later this summer and see photos of her beautiful baby!
The Carling Adrenal Center is a worldwide destination for the surgical treatment of adrenal tumors. Founded by Dr. Tobias Carling MD, PhD, the center performs more adrenal surgery than any other hospital in the world.
Interesting case of the week: Subclinical Cushing’s syndrome patient traveled all the way from Australia!
There are a lot of healthcare providers that do not know enough about Cushing’s syndrome. This is not only true in America, but it is true in Europe, Australia, and all throughout the world. Many doctors think it is a very rare disease and that adrenal tumors do not need to be taken seriously.
This week's patient came to us all the way from Australia. She is the first patient with an adrenal tumor from Australia to be operated on at the brand the Hospital for Endocrine Surgery, which opened in Tampa in January 2022.
She had a long journey. She flew from her hometown in Queensland to Sydney, then from Sydney to Dallas, and finally to Tampa.
When you have subclinical Cushing’s syndrome, it is due to a tumor of the adrenal gland that is producing too much cortisol. Too much cortisol can cause a lot of symptoms. This patient was experiencing heartburn, heart palpitations, leg and arm cramps, muscle weakness, decreased sex drive, difficulty concentrating, difficulty with memory, facial rounding and plethora, supraclavicular and dorsocervical fat pads (fat deposits on the back; 'buffalo hump'), easy bruising, poor wound healing, stretch marks, anxiety, hirsutism (excessive facial hair), low blood potassium (hypokalemia), weight gain with central obesity (meaning unusual fat deposition around your abdomen), excessive sweating, panic attack symptoms (fear, anxiety).
Her doctor had tried her on a medication called for fluconazole. Fluconazole is really an anti-fungal medication. It works very well for fungi and other yeast infections. However, it has a side effect of affecting the cortisol production from the adrenal gland. Like any other medications for Cushing’s syndrome, the medication does not help the root cause. Medications do not remove the tumor. They just temporarily lowers the cortisol in your body. Medications do not work and made our patient ill.
Figure 1: Her CT scan showing the left adrenal mass
The patient had a mini back scope adrenalectomy which took 22 minutes. Can you imagine traveling for two days to have a 22-minute operation? Well, trust me... It’s a lot better than traveling 20 minutes to the hospital down the street to have an eight-hour long operation with complications (or worse).
Figure 2: The left adrenal tumor
Fortunately, the patient made the trip into a mini vacation and will enjoy Florida's beautiful springtime!
Today's patient is a 61-year-old lady who is local from Florida. She presented with signs of symptoms of bone pain, fatigue, insomnia, difficulty sleeping and problems with concentration. She had had a CT scan that indicated a 2.5 cm right adrenal mass.
She had a proper work up and everything was negative except that there was an indication that she had slight cortisol overproduction. Her ACTH level was low, and she failed her low-dose dexamethasone suppression test. This indicated Subclinical Cushing’s syndrome.
Interestingly, the patient also had by chemically unequivocal primary hyperparathyroidism. Her calcium had been ranging between 10.7-10.9 mg/dl and the parathyroid hormone (PTH) was non-suppressed at 58 to 59 ng/l. Her vitamin D levels, and creatinine were all normal. This proves that the patient not only have subclinical Cushing’s syndrome from a right adrenal mass but also a parathyroid tumor causing primary hyperparathyroidism.
You may not know, but parathyroid tumors were Dr. Carling‘s first love when it came to endocrine surgery. In fact, he defended his PhD dissertation in 1997 with a thesis entitled “Vitamin D receptor and estrogen receptor gene polymorphisms in primary hyperparathyroidism”. As a 23-year-old, he published his first paper on parathyroid tumors and primary hyperparathyroidism in Nature Medicine (one of the world’s most prestigious scientific journals). In addition to being the world’s #1 top adrenal surgeon, Dr. Carling is not only one of the most prominent scientists when it comes to primary hyperparathyroidism and parathyroid tumors, but has also performed thousands of parathyroid operations. Nowadays, he spends two full days doing up to 6 to 8 adrenal operations each day for two days, but he loves parathyroid surgery so much that he saves one full day for parathyroid surgery still. He and his team do up to 30 parathyroid operations in that single day! This is >95% of American hospitals perform in a year.
So, what could be better? Getting both your adrenal tumor and parathyroid tumor fixed at the same time!
Figure 1 shows the right adrenal tumor measuring about 2.5 cm.
The tumor was easily removed using the mini back scope adrenalectomy (MBSA). The operation was very straight-forward and took 13 minutes.
The patient spent one night in the hospital to make sure that her heart rate and blood pressure as well as cortisol was fine the next morning.
She then went down for her parathyroid surgery.
Figure 2 shows a very typical right upper parathyroid adenoma of the ultrasound that Dr. Carling performed before the operation.
At the Norman Parathyroid Center, we perform all operations with two surgeons. We have a very unique and (in my mind) excellent philosophy. We believe in the team approach and putting our ego aside, we make sure that at least two world-class surgeons perform each surgery.
Figure 3 shows Dr. Carling and Dr. Parrack, working together on this patient making sure we are not the only removing the parathyroid adenoma, but also identifying and evaluating the other three parathyroid glands, which in this case were all normal. This mini-parathyroid operation took 15 minutes. Usually, Yale and Columbia are rivals in the Ivy leagues but here we work together for the best of the patient!
Figure 4 shows the parathyroid tumor (adenoma) which is approximately 30 times normal after was removed. The patient’s parathyroid hormone (PTH) level in the recovery room was 14, which is exactly where Dr. Carling wants it to be. This proves that the patient is now cured from her primary hyperparathyroidism as well as her subclinical Cushing syndrome.
It is definitely worth it to travel from around the world to Tampa to have the best possible surgery by the Carling Adrenal Center and Norman Parathyroid Center.
For some reason, recently we have had several young patients from California with adrenal tumors. Today we have a 33-year-old, otherwise super healthy, young lady. She is a young mom and has a six-year-old who was delivered by C-section in 2016. She had no problems with high blood pressure during the pregnancy but the last 2-3 years she started to have high blood pressure in addition to many other symptoms. She had problems with heart palpitations, leg and arm cramps, muscle weakness, problems with concentration and memory, irritability, reduced sex drive, low potassium, pallor, excessive sweating, and problems with dizziness. These are all common symptoms from primary hyperaldosteronism and Conn’s syndrome.
Fortunately, she saw a smart cardiologist who thought it made no sense that an otherwise super healthy and slender 33-year-old young mom should have those symptoms along with very high blood pressure. They accurately measured the aldosterone level, which was high, and the renin level, which was very low. This proved that she had primary hyperaldosteronism or Conn’s syndrome. They also obtained a CT scan that showed a typical right adrenal mass measuring about 1.7 cm. Importantly, the left side was completely normal.
Figure 1 shows the aldosterone-producing adrenal adenoma (1.7 cm, arrow) on the CT scan.
This is as textbook “slam dunk” Conn’s syndrome or primary hyperaldosteronism comes. This patient does not need adrenal vein sampling (AVS) or any other test.
Fortunately, she probably only had this tumor for a few years and was spared kidney failure, strokes, heart attacks and heart arrhythmia.
Read about long-term complications of untreated (or just BP medications) Conn’s syndrome here: The aldosterone-producing adrenal adenoma was successfully removed through a 14-minute Mini Back Scope Adrenalectomy (MBSA).
This patient is now completely cured of her primary hyperaldosteronism and Conn’s syndrome and is doing very well! She is ready to get on with her life and do all the fun things she used to do.
From our lovely patient:
"I will forever be grateful for Dr. Carling. Your enthusiasm, knowledge, and dedication regarding adrenal illness is unmatched. I am feeling like my old self again! Blood pressure has returned to normal, headaches have ceased, and fatigue is now a thing of the past. I have attached a picture that I absolutely love. Please feel free to share it however you please. I am very proud of it, as you should be too! Stay well and keep changing lives for the better ❤️."
Remember, if you are a young patient (meaning less than 50 years old) and you do not have any significant risk factors (smoking, diabetes, obesity, etc.), there is no reason you should have high blood pressure. Do not give up! You are your own best advocate.
Can you have a pheochromocytoma of the neck? Well, yes and no.
Paragangliomas, or carotid body tumors, are neuroendocrine tumors that arise close to the main artery of your neck, called the common carotid artery. They are called paragangliomas or carotid body tumors. However, they arise from the same cell types as pheochromocytomas from the medulla of the adrenal gland so in essence they are pheochromocytomas of the neck. So yes, you sort of can have a pheochromocytoma of the neck!
The patient is a 69-year-old woman from Idaho. She had known paraganglioma of her right carotid body for many years. It had plagued her significantly and she had a lot of symptoms with tremors, excessive sweating, panic attacks with anxiety and dizziness especially with standing. Those are all very typical symptoms of paragangliomas (carotid body tumors) of the neck.
Her doctors checked her hormone levels including adrenaline-type hormone (metanephrines and normetanephrines) and they were only mildly elevated. However, this is quite typical in neck paragangliomas and carotid body tumors. Patient can still have a lot of symptoms, though!
She traveled around the Mountain West and the West Coast of United States and every surgeon she saw at the at the major university hospitals were too afraid to operate on her, so she contacted us.
What is better than having the best pheochromocytoma and paragangliomas surgeon taking care of you? How about two of the world's best surgeons working on you.
Dr. Carling (Carling Adrenal Center) and Dr. Clayman (Clayman Thyroid Center, and an expert in advanced head and neck cancer) decided to work together on this case. They literally operate next to each other every day. This is an example of the beauty of the Hospital for Endocrine Surgery. You have the top 11 endocrine surgeons in the world when it comes to adrenal, parathyroid and thyroid disease all working in a cohesive manner literally side by side.
Dr. Carling consulted with the patient over the phone and reviewed the images together with Dr. Clayman and the patient flew down to Tampa for her surgery.
Figures 1 and 2: You can see her right carotid body tumor, paraganglioma. A yellow arrow indicates the tumor. As you can see the tumor is very vascular and all the major vessels including the internal jugular vein the common carotid artery, the external carotid artery (ECA) and, the internal carotid artery (ICA) are all intimately involved with the tumor. The tumor is literally splitting the ICA and ECA apart
Figure 3 shows Dr. Carling and Dr. Clayman working very meticulously but efficiently removing the tumor. In the end, the patient (who had been declined surgery at many famous medical institutions) had the tumor removed by Dr. Carling and Dr. Clayman in under an hour, very safely.
Figure 4 shows the operative field after that the dissection. It shows the internal jugular vein (IJV) the common carotid artery (CCA) as well as the internal carotid artery. The nerve number X (vagus nerve) and the nerve number XII (hypoglossal nerve). The vagus nerve controls your voice, and the hypoglossal nerve controls the function of the tongue. All important vessels and nerves were completely preserved, and the patient had perfect function afterwards.
The patient is a 55-year-old man from Miami. Over the previous months he had noticed gynecomastia (breast tissue developing in a man), tiredness, and decreased libido (sex drive). He had actually seen a surgeon to have his breast tissue removed (never performed, fortunately), but via a circuitous route was referred to an endocrinologist.
This doctor understood what was going on and ordered laboratory test and an MRI scan of his abdomen. The laboratory test showed very high cortisol levels (Cushing’s syndrome, causing his fatigue) and high estrogen levels (leading to feminization causing breast development and decreased sex drive). The MRI demonstrated a huge left adrenal mass.
The patient had seen a number of surgeons and been recommended everything from biopsies (don’t get me started #1), to radiation and chemotherapy (don’t get me started #2). What this patient needed was an operation.
Chemotherapy should never be used unless surgery is no longer an option.
Figure 1 shows the huge mass (> 10 cm) of the left adrenal gland on the CT scan.
Figure 2 shows the breast development in a man (gynecomastia) on the CT scan (yellow arrows).
This case illustrates the less than 3 % of patients where the mini back scope adrenalectomy (MBSA) is not the appropriate operation. The best operation in this case is the laparoscopic transabdominal hand-port assisted adrenalectomy, which is the operation he had. Although the tumor was very close to some major structures and vessels (stomach, pancreas, colon, left kidney, spleen, splenic artery and vein, and renal artery and vein), all those structures were preserved and there was zero blood loss.
We have already set up a team of doctors who will keep a very close eye on him for many years to come. His gynecomastia and Cushing’s syndrome will be cured and slowly disappear. His libido will return.
Ahhh…remember back when you were 21 years old… You were strong, had endless energy, and the whole life ahead of you. You had probably just started working your first job or you were studying at college or university.
The last thing on your mind was worrying about being sick, especially by an adrenal tumor spewing out toxic levels of dangerous hormones.
Well, meet one of my recent patients. He is 21-years-old. For some time before coming to the Carling Adrenal Center he had experienced heart palpitations (strong heart beats), excessive sweating and episodes of elevated blood pressure. Fortunately, he had a smart cardiologist who took his symptoms seriously and ordered labs. His catecholamines and metanephrines (adrenaline-type hormones) were more than 10 times normal. An MRI demonstrated a 4.1 cm left adrenal mass. The diagnosis of left adrenal pheochromocytoma was established.
Fortunately, our 21-year-old was one of our local patients and lived only about 3 hours’ drive away (we regard anyone living in Florida as “local” patients). He was started on an alpha blocker called Phenoxybenzamine until he was ready for surgery. His mom was a bit nervous because she was told (by health care professionals) that the pheochromocytoma could burst. Pheochromocytoma do not burst while on alpha blockers. In fact, we have patients with pheochromocytomas flying in from all over the United States and the world for surgery, and they all do just fine. However, if the catecholamines and metanephrines (adrenaline-type hormones) are >5 times elevated we like them to be on an alpha blocker medication prior to surgery and when they travel to Tampa.
Figure 1: This photo was taken with an endoscope which is the type of camera Dr. Carling uses in the operating room. The left adrenal vein draining the pheochromocytoma can be seen and Dr. Carling has placed a clip (yellow arrow) so it can be divided off the left renal vein. As you can imagine it requires superb skill to do this operation perfectly.
Figure 2: The bad pheochromocytoma tumor can be seen here.
He had an 18-minute mini back scope adrenalectomy (MBSA). He is now cured. This is a done deal, and he can get back to doing all the fun things a 21-year-old young man should do!
The patient is a 57-year-old woman who had a known left adrenal mass, which likely was related to a previous episode of bleeding (hemorrhage). Bleeding in a normal adrenal gland or a pre-existing tumor can be problematic. As the area heals, it sometimes forms a peripherally calcified mass, meaning, there is calcification formed at the outer layer of the adrenal mass.
The mass occasionally bothered her with pain in the area. The patient’s laboratory investigation was normal, except for low cortisol levels. However, she had chronically been maintained on hydrocortisone for cervical disc disease, which explained this.
The tricky thing with adrenal tumors containing calcifications is that we can see this in both benign and cancerous cases. Adrenal cortical adenomas, adrenal carcinomas, previous adrenal hemorrhage, adrenal metastases, pheochromocytomas, and some infectious processes of the adrenal all can manifest as a calcified mass
She underwent a CT scan which you can view in the photos shown here. The yellow arrow indicates the large left adrenal mass.
Reviewing the CT scan made me quite confident that this was a not cancerous. However, when these masses are symptomatic (as in our patient’s case) they need to be removed by surgery.
The patient was an excellent candidate for the mini back scope adrenalectomy (MBSA), and did tremendously well after the operation.
Next, she will work with her endocrinologist to wean off her hydrocortisone. Unfortunately, she was placed on steroid for her cervical disc disease, and now her right adrenal gland (the one remaining) is iatrogenically suppressed by long term steroid use. Over time it will wake up, but it may take several months. Don’t stay on steroids longer than you absolutely have to!
A mass that is cystic means that it contains fluid. Cystic adrenal masses are not uncommon. They include benign cysts like endothelial and epithelial adrenal cysts, as well as pseudocysts. However, actual tumors such as adrenal cortical adenomas and cancers can contain cysts. Pheochromocytomas famously can be cystic, as well.
This week’s patient is a 59-year-old woman who noticed some pain in her left abdomen. She also had some blood in her urine.
She underwent a CT scan, which you can view in the photos here. The yellow arrow indicates a large 7 cm cystic adrenal mass.
Reviewing the CT scan made me quite confident that this was a typical simple cyst, and she had no risk of it being a tumor. However, even simple cysts can sometimes cause problems. The most common symptom is abdominal pain or other GI tract symptoms. When these cystic masses are symptomatic (as in this case) they need to be removed by surgery.
The patient was an excellent candidate for the mini back scope adrenalectomy (MBSA). The patient had this mass removed in a 19-minute, straightforward operation. She quickly returned to normal activities and is doing well. Once the adrenal cyst is completely removed, it will never return.
The Carling Adrenal Center is a worldwide destination for the surgical treatment of adrenal tumors. Founded by Dr. Tobias Carling MD, PhD, the center performs more adrenal surgery than any other hospital in the world. The Center is located within the famous Hospital for Endocrine Surgery in Tampa, Florida.
The Hospital for Endocrine Surgery is the only hospital of its kind in the entire world. It is a full-fledged hospital with an Emergency Department (ER) and in-hospital beds (not a “surgery center”). The hospital is dedicated solely to patients with adrenal, parathyroid, and thyroid disease. It is brand new, very clean and there are no infectious disease patients or any other type of patients.
The first patient we had the honor of welcome is a 53-year-old lady from California. She, like many of our patients, experienced symptoms of an adrenal tumor for a long time before she was diagnosed. She was diagnosed initially with high blood pressure and atrial fibrillation. Atrial fibrillation is when your heart is skipping beats. An adrenal tumor is a very common underlying cause of atrial fibrillation.
Further work up revealed that she had a right adrenal mass and her laboratory tests proved that it was over-producing adrenaline-type hormones; catecholamines. This proves that she had a pheochromocytoma.
The photo below was taken with an endoscope, which is the type of camera Dr. Carling uses in the operating room. As you can see, he is peeling the pheochromocytoma off the inferior vena cava (IVC; the major vein in our body). As you can imagine, it requires superb skill to do this operation perfectly.
The patient did tremendously well! She is completely cured from her high blood pressure and could come off all her medication she was taking before the operation. She was able to leave the hospital first thing in the morning and is traveling back to California.
The patient is a 51-year-old woman with primary hyperaldosteronism (Conn’s syndrome). This is due to an aldosterone-producing tumor of the adrenal gland. Her aldosterone level was high and her renin level low, proving primary hyperaldosteronism.
The patient was quite ill from this disease. In addition to high blood pressure heart palpitation and anxiety, she also had significant leg and arm cramps, as well as muscle weakness. Because of this she was not very mobile and one of her major concerns was how to be able to travel from Mississippi to Tampa for her adrenal operation.
Her CT scan shows a 2.2 cm right aldosterone-producing adrenal adenoma (yellow arrow).
Fortunately, our patient found out about a great volunteer organization that privately flies people throughout the Southeast for specialized medical treatment for free.
ANGEL FLIGHT SOARS is a volunteer pilot organization serving those who reside in, are traveling to or through the states of Georgia, Alabama, Mississippi, Tennessee, North Carolina and South Carolina.
Angel Flight Soars serves the community by coordinating free non-emergency air transportation to life-changing medical care that is not available locally, and for other compassionate purposes for the benefit of the community. They are dedicated to coordinating free flights on private aircraft with volunteer pilots and to working with the medical community to arrange these services for the community in need. The majority of their missions are flown in single- or twin-engine, four- to six-seat aircraft. www.AngelFlightSoars.org
Her pilot landed her in Tampa, and after undergoing a 19-minute right mini back scope adrenalectomy (MBSA) she was cured of her primary hyperaldosteronism.
The bad aldosterone-producing adrenal tumor is pictured here.
This week I saw a 51-year-old man from Illinois who developed a COVID-19 infection in September. He became relatively sick to the point where he required going to the emergency room where he was diagnosed with COVID-19 pneumonia.
They treated him with monoclonal antibodies, and he did well. Given that he had pneumonia, the ER doctors had performed a CT scan of his chest where they observed a 3 cm right adrenal mass.
Fortunately, his doctors did not ignore this mass, but referred him for a hormonal work up as well as a follow up MRI. The laboratory tests showed that he had slightly elevated 24-hour metanephrines. His normetanephrines as well as total metanephrines were about twice the upper limit. These findings are borderline when it comes to diagnosing pheochromocytoma. Most patients with pheochromocytoma have adrenaline-type hormone levels that are > 5 to 10 times normal. However, we certainly see patients with mild elevation as well. The follow up MRI demonstrated some features consistent with a pheochromocytoma.
He contacted us here at the Carling Adrenal Center and we swiftly reviewed all his information.
The right adrenal mass (yellow arrow) on the CT scan is shown in this picture. The white arrow indicates a normal left adrenal gland. Read more about imaging and X-ray studies of adrenal tumors here: https://www.adrenal.com/adrenal-tumors/scans
The patient underwent a 23-minute mini back scope adrenalectomy, and he did tremendously well.
The pathology did reveal a 3.5 x 3.0 x 2.7 cm right pheochromocytoma.
COVID-19 is a bad disease, but at least in this case it facilitated the early diagnosis of this patient’s pheochromocytoma. A swift surgical cure means that this patient will be spared all of the potentially catastrophic complications of undiagnosed pheochromocytoma.
Often the medical history, pathology or clinical presentation are unusual and interesting in our adrenal patients. Additionally, their lives and circumstances always fascinate me. Each patient has their own story, and it is always worth telling. Occasionally, patients come from the local Tampa Bay area, but more than 60% of our patients come from outside of Florida.
Due to the Covid-19 pandemic, it has been more challenging for our worldwide patients to fly into Tampa for the best possible adrenal surgery care. Nonetheless, some have been able to come, and as international travel is becoming more frequent again, so are our global patients.
The patient is a 55-year-old lady originally from the United Sates, but who currently lives and works in Cameroon, Africa. She did not have a lot of symptoms, and a CT scan (done for other reasons) in early January performed in Cameroon demonstrated a 3.6 cm partially calcified left adrenal tumor. The biochemical workup was unremarkable and showed no overt hormone overproduction.
Wisely, the patient was scheduled for a follow up imaging study, which now in September suggested that the tumor had grown to 5.8 cm. Interval growth and a tumor size over 4 cm are indications for surgery.
The patient flew in from Africa and underwent a 21-minute left mini back scope adrenalectomy (MBSA) for the left adrenal mass.
Fortunately, the pathology revealed a benign (non-cancerous) tumor, and the figure demonstrates the tumor with surrounding normal adrenal and fibroadipose tissue.
She was able to swiftly recover and return to her important work serving the people of Cameroon. We were honored to take care of her.
The patient is a 62-year-old lady from Austin, Texas. She did not have a lot of symptoms, but she did have high blood pressure. An MRI of her adrenals had demonstrated a 3.9 cm right adrenal tumor which the radiologist suggested could be concerning for adrenal cancer or possibly pheochromocytoma.
Her doctors correctly had checked her hormone levels and, indeed, her plasma free metanephrines and normetanephrines were all elevated. This clinches the diagnosis of pheochromocytoma. She was correctly placed on blood pressure control (alpha blocker) in preparation for surgery.
For some unfathomable reason, her doctors had talked to her about having a biopsy of the adrenal mass. Fortunately, the patient had read up on adrenal.com and called me before anybody could potentially put the needle into her adrenal mass. BIOPSY OF A PHEOCHROMOCYTOMA IS CONTRAINDICATED. Just don’t do it!
Doing a biopsy of an adrenal pheochromocytoma is not only completely useless but is potentially dangerous because it can release the adrenaline type hormones and lead to severe bleeding and a spike in the blood pressure resulting in stroke.
Learn more about the top 5 symptoms of pheochromocytoma.
You can review her Adrenal CT scan with contrast in figure 1A and figure 1B. The yellow arrow indicates the right adrenal pheochromocytoma.
Interestingly, the patient also had a large symptomatic left thyroid nodule. Anytime you have a thyroid nodule together with a pheochromocytoma you always need to keep medullary thyroid cancer and multiple endocrine neoplasia type 2 (MEN2) in the back of your mind. However, her calcitonin levels were normal which effectively rules out medullary thyroid cancer. Thus, her thyroid mass was likely just a benign thyroid goiter. However, she was sufficiently symptomatic with difficulty swallowing, choking as well as globus sensation.
You can review her thyroid ultrasound here in figure 2A and figure 2B. The yellow arrow indicates the large left thyroid nodule that is pushing on her windpipe (trachea) and food pipe (esophagus).
The patient flew down and on Tuesday underwent a 19-minute right mini back scope adrenalectomy (#MBSA) for her right adrenal pheochromocytoma. The patient did very well and spent one night in the hospital and Wednesday morning we took her back to the operating room and did a left thyroid lobectomy. The thyroid operation lasted two minutes longer.
The final pathology revealed a 4.6 cm pheochromocytoma completely resected and a 3.1 cm left thyroid follicular adenoma with no capsular or vascular invasion. EXCELLENT NEWS. The patient had curative resection of both her endocrine tumors and returned shortly to Texas and can put this all behind her.
So, what could be better? – Getting both her pheochromocytoma and thyroid follicular adenoma cured in one trip to beautiful Tampa, Florida.
The patient is a 69-year-old woman with an incidentally noted right adrenal tumor.
She had a CT scan back in September 2020 to evaluate a kidney cyst on the left side. The scan picked up on a nodularity on the right adrenal gland measuring 2.1 cm.
Fortunately, her doctors did not ignore her adrenal tumor. She was also sent to a medical endocrinologist who did a complete hormone work up. They made sure she did not have aldosterone-, cortisol-, or adrenaline- overproduction.
One year later they repeated the CT scan. Now the tumor had grown to 2.5 cm. On the CT scan there the tumor had an “atypical imaging phenotype”. This means that the tumor has some concerning features. The tumor was lipid-poor. This means that it does not have a lot of fat in it. This is a concerning sign.
At this point the patient was referred to me. When I reviewed all her scans, I was sufficiently concerned about this tumor that I recommended surgery. I recommended surgery even though the patient did not have any symptoms.
I review all the scans myself in great detail. I have looked at thousands of adrenal tumors on CT, PET and MRI scans. Her scan was concerning to me.
The patient underwent an uncomplicated right mini back scope adrenalectomy (MBSA). The operation lasted 21 minutes.
Two days later our specialist adrenal pathologist called me. Indeed, the suspicion I had about the scans was verified. The patient had an adrenocortical cancer (also known simple as adrenal cancer, or ACC).
Fortunately, because it was detected early it was still Stage 1. Importantly, all the margins were negative. This means the cancer was completely removed. It is likely that the patient will have a surgical cure and do very well.
We have already set up a team of doctors who will keep a very close eye on her for many years to come.
The patient is a 61-year-old woman with a cortisol-producing right adrenal tumor causing subclinical Cushing’s syndrome.
Patients with subclinical Cushing’s syndrome have too much cortisol and can suffer from many signs and symptoms.
Heartburn, heart palpitations, muscle weakness, decreased sex drive, difficulty concentrating, anxiety, problems with memory, and Irritability are common symptoms of Cushing’s syndrome.
Patients can gain weight, especially on the mid-section, and their back, so called 'buffalo hump', and often develop diabetes.
Easy bruising, poor wound healing, hair loss, and sleep apnea are other symptoms of too much cortisol.
The tricky thing with subclinical Cushing’s syndrome is that the symptoms often sneak up on the patient over months and years. Many patients don’t even realize how bad they feel because they attribute their symptoms to getting older. Sometimes, they do not realize how bad they really feel until the adrenal tumor is removed.
This patient had an incidentally identified adrenal tumor on a CT scan for another reason. Fortunately, her doctors did not ignore the tumor. They ordered appropriate lab test. She had a low (suppressed) ACTH level, and a cortisol level over 1.8 following a low dose dexamethasone suppression test. This proves adrenal subclinical Cushing’s syndrome.
The patient had a Mini Back Scope Adrenalectomy and did very well. She did not require steroids after the operation.
6 weeks later the patient contacted me and said she felt better than she had done in decades. Her energy level improved, and the brain fog was gone. She had already lost 7 lbs., and her blood sugars normalized to the point where she was no longer pre-diabetic. She was thrilled to get rid of the toxic effects of too much cortisol. She wished she had gotten rid of her adrenal tumor a long time ago.
This week, I had the honor of operating on a 59-year-old woman with an unfortunate history of stage 4 cancer arising from her uterus.
She had undergone massive surgery with removal of her uterus, ovaries as well as other organs in her pelvis. She had done quite well for some time but follow-up scans showed a large mass on her left adrenal gland.
Additional scans showed no other evidence of metastasis (meaning spread of the cancer) except to the left adrenal gland. Whenever there is an isolated metastasis to the adrenal gland, surgery is recommended.
She traveled from the Midwest to the Carling Adrenal Center in Tampa to have her surgery. Review her CT scan with me here, showing a large left adrenal mass as well as what the mass looks like after it was removed.
The patient had a Mini Back Scope Adrenalectomy, and even though the tumor was very large (9 cm, Fig 1), the operation took less than 30 minutes. The patient very much benefited from having surgery through the back as supposed to through the abdomen. Having the Mini Back Scope Adrenalectomy meant that we could avoid all the scar tissue from her previous cancer operation of her uterine cancer.
She flew back home a couple of days later and will continue to be closely followed by her local oncologist.
Adrenal masses in young patients should always be taken very seriously. In young patients, the risk of it being cancerous or hormone-producing is much higher than in older people.
This is a patient from Louisiana. He is very young, in his early 20s, and had undergone a CT scan of his abdomen. The scan was performed for other reasons but there was a finding of an incidental large left adrenal mass.
It measured 5.3 cm (greater than 2 inches) and it had some characteristics on the scan that was atypical or indeterminate. The patient did not have any symptoms but of course we measured all his hormone levels (cortisol, aldosterone, and adrenaline-type hormones) which were all negative.
As you know, one should almost never perform a biopsy of an adrenal tumor so clearly this tumor needed to come out.
He came down here for his operation and had a very straightforward left Mini-Back Scope Adrenalectomy (MBSA)
Our expert endocrine pathologist called within two days and gave me the very good news. This was a benign adrenal ganglioneuroma. Ganglioneuromas of the adrenal gland are rare. In the photo placed at the end of the video, you can see how the tumor arises just adjacent to the normal adrenal gland. These tumors are all benign, meaning not cancerous, and he is completely cured.
He will live a perfectly normal life and will never have to worry about this again.
High blood pressure, low potassium, fatigue, and muscle cramps occur in many patients with Primary Hyperaldosteronism also known as Conn’s syndrome.
The cause of Primary Hyperaldosteronism often is a small adrenal tumor that overproduce aldosterone. Too much aldosterone is very toxic for the body.
This patient is a doctor herself in Texas and in her early 40s. She is otherwise super-healthy and did not have any real for having high blood pressure. She had classical Conn’s syndrome.
She had a CT scan that did not show an obvious adrenal tumor. Fortunately, she was smart and so was her doctor, so they did not give up on her.
She underwent adrenal vein sampling, which directly measure the aldosterone production from each adrenal gland. This clearly proved that the left adrenal gland had a tumor.
She underwent a swift Mini Back Scope Adrenalectomy (MBSA).
Now the patient is cured of her primary hyperaldosteronism and Conn’s syndrome and is doing fantastically.
So, remember, even if the tumor does not show up on a CT or MRI, that does not mean you do not the disease. It just means that the tumor is not large enough to be picked up on a regular scan.
Cortisol production by the adrenal glands is normally under the control of the pituitary (a small endocrine gland located in the bran right behind your eye). When a pituitary tumor secretes too much ACTH (adrenocorticotropic hormone), it causes the otherwise normal adrenal glands to produce too much cortisol. This type of
Cushing's syndrome is termed Cushing's disease.
The treatment for this is pituitary surgery to remove the tumor. When pituitary surgery works (70%), it is great! However, about 1/3 will never be cured in the fist place or the tumor grows back (recurrence). This is a BIG problem.
In these patients removing all cortisol-producing cells, meaning bilateral adrenalectomy is often the best option. The goal is to remove all cells in the adrenal glands overproducing the toxic cortisol.
Many recent studies have shown that bilateral adrenalectomy is an increasingly used and essential treatment option when pituitary surgery is no longer an option. Compared to other options such as radiation or medical treatment, bilateral adrenalectomy lowers morbidity and mortality rates, as well as improves quality-of-life.
Again, the Mini-Back Scope Operation (MBSA) is the best adrenal operation for “failed” ACTH-dependent Cushing’s syndrome, Cushing’s Disease. Do not go through the tummy to get to the adrenal glands!
The symptoms of adrenal pheochromocytoma can be variable, and often missed by doctors for years and decades. Check out the top 5 symptoms of pheochromocytoma.
All symptoms of a pheochromocytoma are due to the very toxic effects of too much adrenaline hormones (catecholamines).
Symptoms from a pheochromocytoma are often characterized by “spells”. This means patients develop symptoms from the pheo during an attack, a “spell”, which often last 5 to 20 minutes. The typical spell is associated with very high blood, headache, palpitations (heart racing), and sweating. Chest or belly pain is also common
However, not all patients with pheochromocytoma have symptoms. As many as 30% of pheochromocytoma patients have no symptoms.
Let me introduce you to a very pleasant female patient of mine.
She is 77 years old, but strong as an Ox. She still works her farm, from sunrise to late into the evening.
Indeed, sometimes I had difficulty tracking her down because she was running around the farm on her tractor. At 77 years old. She is one tough Florida lady.
She felt fine. She felt strong. The only problem she had was high blood pressure.
She did have a CT scan though for other reasons, and this showed a 2.3 cm right adrenal tumor (see Figure 1).
This tumor did not look like a typical innocent benign (non-cancerous) adenoma, so her doctor ordered a PET scan, which also showed some concerning features (review video of her CT scan here: https://youtu.be/Wx0VpahVVLw).
Clearly, she needed surgery. We did measure her adrenaline hormones (Catecholamines, Metanephrines), and they were only slightly elevated.
I performed a 16 minute Right Mini Back Scope Adrenalectomy (MBSA). I almost always can tell in the operating room when I look at the tumor, I can tell what it is, and I knew instantly that it was a pheochromocytoma (see Figure 2). She did awesome!
My sweet 77-year-old famer lady did great and was back on her tractor working within a couple of days.
So, remember, not all pheochromocytoma patients have symptoms!Interesting case of the week 9/17/2021: Right pheochromocytoma, no symptoms with Dr. Tobias Carling
Cushing’s syndrome or too much cortisol is probably the one disease that confuse the most doctors, nurses and patients. But when it comes to adrenal Cushing’s syndrome, it is actually quite straightforward. Adrenal Cushing’s syndrome means too much cortisol that originates from the adrenal gland. This is either from one adrenal tumor or from both adrenal glands, called bilateral adrenal Cushing’s syndrome.
Another name for Cushing’s syndrome due to masses of the adrenal glands is ACTH-independent Cushing’s syndrome. This differentiates it from Cushing’s Disease which is ACTH-dependent. The problem then is a tumor in the pituitary gland of the brain overproducing ACTH.
To diagnose Cushing’s syndrome, lab tests prove that the patient have too much cortisol production. This can be done through a number of tests including the low-dose dexamethasone suppression test, a salivary cortisol test, or a 24-hour urine collection for cortisol. If the ACTH level (which is the pituitary hormone that controls the adrenal) is on the low side or frankly suppressed that proves that the problem originates in the adrenal glands.
The patient is a doctor from Southern California. He has for many years had adrenal Cushing’s syndrome. His ACTH level has always been low, but his cortisol level has been high. This has been proven multiple times through 24-hour urine collection and low dose dexamethasone suppression test.
He had many very difficult symptoms with muscle weakness, decreased sex drive, problems with concentration and memory, anxiety, low potassium, high blood pressure. He was required to take multiple medications including blood pressure medication and extra potassium although otherwise, he was a very fit and healthy person. All these symptoms affected his quality of life and his work as a doctor.
His doctor had started him on a medication called Korlym. Korlym is a drug that blocks the cortisol effect. This medication does not fix the problem. It is not a cure for Cushing’s syndrome. It does not remove the tumors in the adrenal glands.
However, sometimes it can treat the symptoms and make life a little bit more bearable for the patients until they can have surgery and get cured of the disease.
So, he was started on Korlym until he could come to me in Tampa for his adrenal gland removal.
A couple of months ago, I performed bilateral cortex-sparing adrenalectomy on him. This was done by the Mini Back Scope Adrenalectomy (MBSA) approach. I removed almost all adrenal tissue except leaving about 30 to 50% of one adrenal gland. This is because he had bilateral tumors, meaning tumors on both the right side and the left side. This left the perfect amount of adrenal tissue such that he was cured of his Cushing’s syndrome, but also has enough cortisol production that he does not need to take long-term steroid hormone supplementation. This is a “Goldilocks” operation, meaning the amount of adrenal tissue remaining is “just right”.
Now the patient is cured of his Cushing’s syndrome and is doing very well. He required a short period of time (a few weeks) to take supplementary cortisol (Prednisone) until the remnant adrenal gland tissue produced enough cortisol by itself.
I love radiologists.
In fact, my younger brother and my best friend from medical school are both radiologists. But radiologists sometimes miss things, and this is especially true when it comes to #adrenaltumors. In particular, small aldosterone producing #adrenaladenomas can easily be missed.
These small adrenal adenomas that overproduce aldosterone cause primary #hyperaldosteronism or #ConnsSyndrome.
Often these aldosterone-producing adrenal tumors are quite small, less than half an inch or about one centimeter. The is the size of a pea or a small grape.
Why do radiologists miss small adrenal tumors on CT scans?
Radiologists look at hundreds of CT scans in a single day. They look at dozens and dozens of different organs in your body. When a radiologist looks at the CT scan of the chest and abdomen, they review the lungs, heart, liver, kidneys, spleen, pancreas, bowels, and all sorts of different organs. A small adrenal tumor can easily be missed.
The patient in her mid-fifties from the Mountain West had high blood pressure for decades. She was not overweight, diabetic or had any real reasons for having high blood pressure. Despite this, she required 4 blood pressure medications including Spironolactone.
Her aldosterone level was very high and her renin level very low (suppressed). She also had problems with too low potassium. She had a potassium as low as 2.4 once. This is dangerously low. She was a “slam-dunk Aldo”. This means it is so obvious that a 3rd year medical student should be able to diagnose it.
However, on the scan of her adrenals, the report stated that the adrenal glands were normal.
When I reviewed her CT scan, she had on obvious left adrenal tumor, measuring 13 mm.
Figure 1 and 2 shows the aldosterone-producing adrenal adenoma on the CT scan and after it was removed by a 19-minute Mini Back Scope Adrenalectomy (MBSA).
Now the patient is cured of her primary hyperaldosteronism and Conn’s syndrome and is doing fantastically.
So, remember, it is very important that the radiologist knows that you have an adrenal problem, and that they scrutinize the adrenal gland on the scan very carefully.
This week, I saw a patient with cancer that had spread to the adrenal gland. This is called adrenal metastasis and occurs most commonly with breast, lung, kidney, colon, rectal, and stomach cancers as well as malignant melanoma. Adrenal surgery is used to treat and sometimes cure cancer which has spread to the adrenal gland. This is advanced surgery and should only be performed by the most experienced adrenal surgeons. You also need your surgeons to be experienced to scrutinize your scans (CT, MRI, PET, etc).
Prior to seeing me, this patient had undergone significant treatment for his kidney cancer. They had already removed his right kidney which contained the original cancer and he was told they removed the left adrenal gland because the cancer had spread.
His cancer had come back in his right adrenal gland and required surgery. He was now facing a dilemma and was told by his doctors that he could have the right adrenal gland removed but would need to take medication for the rest of his life.
When I looked at his scan, I determined his left adrenal gland wasn't actually removed during the original surgery. Watch the video to learn more!