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  • • Incidence has increased with use of ultrasonography, CT, and MRI for various, nonrelated diseases of the abdomen

    • Diagnosis includes such conditions as nonfunctioning adrenocortical adenoma, functioning adenoma, pheochromocytomas with subclinical secretion of hormones, and adrenocortical carcinomas

    • Major issues to determine is whether the tumor is hormonally active or whether it is a carcinoma

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Epidemiology

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  • • Found in 1-4% of CT scans

    • Found in 6% of random autopsies

    • Incidence increases with age

    • Over 80% are nonfunctioning cortical adenomas

    • 5% each are preclinical Cushing syndrome, pheochromocytoma, and adrenocortical carcinoma

    • 2% are metastatic carcinoma

    • 1% are aldosteronoma

    • 25% of pheochromocytomas are found incidentally

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Symptoms and Signs

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  • • Asymptomatic; discovered on imaging study done for nonrelated disease process

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Laboratory Findings

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  • • Depends on type of tumor; nonfunctional adenoma will have no laboratory abnormalities

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Imaging Findings

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  • • Most pheochromocytomas are over 2 cm in diameter and characteristically bright on T2-weighted MRI

    • CT scan findings of heterogeneity or irregular borders are suspicious for malignancy

    • PET scans may be useful in detecting malignant lesions

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  • • Simple adrenal cysts, myelolipomas, and adrenal hemorrhages can be identified by the CT characteristics alone

    • Adrenal cysts can be very large but are very rarely malignant

    • Since most tumors are nonfunctioning adenomas, the work-up should avoid unnecessary procedures and expense

    • Nonfunctioning adrenal tumors that are greater than 5 cm have a high risk of cancer (up to 33%)

    • An adrenal mass > 3 cm in a patient with a previously treated malignancy is very likely a metastasis

    • Tumors that metastasize to the adrenal gland include: lung, breast, colon, hypernephroma, malignant melanoma, uterine, and prostate

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  • • Complete history and physical exam, with specific reference to previous malignancies, symptoms of Cushing syndrome, hypertension, virilization, or feminization

    • All patients, even those without hypertension, should have plasma metanephrines and/or 24-hour urinary fractionated catecholamines determined to evaluate for pheochromocytoma

    • All patients should have a serum cortisol, 24-hour urine collection for cortisol, and an overnight dexamethasone suppression test to assess for Cushing syndrome

    • Patients who are hypertensive should have serum potassium and plasma aldosterone and renin activity measured

    • Consider obtaining a dehydroepiandrosterone (DHEA) level (potential marker for adrenocortical carcinoma)

    • If above studies show the tumor to be nonfunctional, the size of the tumor and the patient's overall medical condition determine management

    • If metastasis is suspected and pheochromocytoma is ruled out, then CT-guided fine-needle aspiration can be useful

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  • • Management depends on functional status and size of the tumor

    • Metastatic adrenal lesions should be treated appropriately in concert with the underlying primary cancer

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Surgery

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Indications

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  • • Hormonally active tumor

    • Adrenocortical carcinoma

    • Consider for nonfunctional tumors > 4 cm

    • Solitary adrenal metastasis

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