Adrenal Tumors

Introduction

Most but not all adrenal tumors are benign (not cancer). Some benign tumors (also known as adenomas) actively secrete hormones in excess causing imbalance of the endocrine system and may lead to high blood pressure either due to increased salt and water retention (aldosteronoma) or vasoconstriction (pheochromocytoma), or fatigue, and weight gain (cortisol secreting adenoma). Non-functioning adrenal adenomas are typically asymptomatic and discovered incidentally (“incidentaloma”) during imaging studies performed for other conditions.

Adrenal cancers are rare but cancers originating in other organs (kidney, breast, thyroid) may spread to the adrenal gland and mimic adrenal adenomas in CT appearance.

Early detection, diagnosis and staging

Adrenal tumors can present with any of the following symptoms:

• No symptoms
• High blood pressure (hypertension), rapid heart rate (tachycardia), flushing, and sweating
• Anxiety and emotional disturbance
• Weight gain, lethargy (tiredness), humping of the shoulder, and blue streaks on the abdomen
• Acne and facial hair; breast development

Patients with adrenal tumors undergo testing with blood and urine tests (to detect increased hormone secretion), and imaging studies such as CT scan, MRI and MIBG scan depending on their clinical situation. These tests determine functional status (i.e. excess hormone secretion) of the adrenal adenoma which is an indication for surgical removal irrespective of the size of the tumor.

While tumors less than 4 cm that do not function need not be removed, adenomas that are 4-6 cm are removed regardless of functional status due to concern of adrenal cancer.

• Pheochromocytoma (epinephrine secreting adrenal adenoma): can produce high blood pressure (hypertension), rapid heart rate (tachycardia), flushing, and sweating. Approximately 10% of pheochromocytomas are malignant, and can spread to other parts of the body (a process known as metastasis). An MRI scan and urine tests for adrenaline and similar hormones are the mainstay of diagnosing a pheochromcytoma.
• Cushing’s Disease: can produce weight gain, lethargy (tiredness), humping of the shoulder, blue streaks on the abdomen, acne, and facial hair. Urine and blood tests will show elevated levels of cortosol.
• Aldosteronoma: can produce high blood pressure and decreased levels of potassium. Urine and blood tests are most useful for its diagnosis.
• Adrenocortical carcinoma: Malignant adrenal tumor which is rare. Characterized by large size of the tumor and often associated with excess secretion of hormones. Treatment is surgical excision.

Treatment

The preferred treatment for adrenal tumors is surgical removal if possible. This can be performed using traditional open surgery or laparoscopy.

Laparoscopic adrenalectomy involves removal of the entire adrenal and the surrounding fatty tissue (all contained within Gerota’s Fascia). This operation is used for adrenal tumors that are larger than 5cm or for smaller tumors that are suspicious for cancer or are producing elevated levels of hormones.

Laparoscopic (minimally invasive with or without the assist of a robot) adrenalectomy is standard of care for adrenal adenomas. Currently, open surgical removal of the adrenal gland is reserved for very large tumors (10 cm) or in cases suspicious for adrenal cancer which appears to invade adjacent vital structures.

In patients with pheochromocytoma, careful preoperative preparation to control high blood pressure enlists the urologist, the medical primary care physician or endocrinologist, and the anesthesiologist as a team with the primary goal of a safe and successful outcome.

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