Approach to adrenal masses: Clinical sciences

Adrenal masses are abnormal growths that develop in one or both adrenal glands, which are triangular-shaped glands located on top of each kidney.

The majority of adrenal masses are benign adenomas, which can be either non-functional, meaning they don’t secrete hormones; or functional, meaning they secrete hormones like normal adrenal tissue would, which can cause specific symptoms depending on which hormone they secrete.

When an adrenal mass is discovered, the two main questions that arise are if the mass is malignant or benign, and if it’s functional.

Now, when a patient presents with a chief concern suggesting an adrenal mass, your first step is to obtain a focused history and physical examination.

Next you must determine if the patient is asymptomatic or symptomatic. If your patient is asymptomatic, Then you should ask about any recent imaging that has been done.

Typically, these patients present after an incidental finding of an adrenal mass was found on CT or MRI performed. Usually for an unrelated issue such as trauma or other intra-abdominal problem. They might also have a history of malignancy, so make sure to ask!

The physical exam is often normal in these patients, leading you to consider an adrenal incidentaloma.

Your next step is to obtain a non-contrast CT scan or an MRI of the abdomen.

If imaging reveals a mass less than 4 centimeters, with regular shape, smooth borders, and a low density of less than 10 Hounsfield units on non-contrast CT, it’s most likely a benign adrenal adenoma.

These tumors have a very low malignant potential and usually remain stable in size. Small benign asymptomatic adenomas do not require any surgical intervention.

Here’s a clinical pearl! Most adrenal incidentalomas are nonfunctional, but those that are at least one 1 centimeter should be investigated further with imaging and biochemical testing to identify adrenal hyperfunction.

Now lets go back and look at malignant masses.

The will present with a mass 4 centimeters or larger, with an irregular shape and irregular borders, and a density of 10 Hounsfield units or more on non-contrast CT

Other findings consistent with malignancy include hypervascularity, necrosis, and calcifications.

These findings should make you suspicious for malignancy and you should consider a malignant mass.

Keep in mind that adrenal malignancy can be primary, but sometimes it can be metastatic, most often from the lungs, kidney, colon, lymphomas, or skin melanomas.

So, if you suspect a malignant mass, your next step is to stage the mass using the TNM system, which might require additional imaging like a PET-CT scan.

Once the tumor has been staged, your patient needs to be referred for a surgical consultation for resection. Often, the diagnosis of adrenal malignancy is confirmed after surgical resection on postoperative pathology of the mass.

Alright, now that we covered asymptomatic adrenal masses, let’s discuss symptomatic or hormonally functional ones.

Here is a high yield fact! The adrenal gland is made up of the adrenal cortex that surrounds the inner adrenal medulla.

The cortex is divided into 3 zones that secrete different hormones.

Starting from the outermost layer and working inward, the zona glomerulosa secretes mineralocorticoids, namely aldosterone; the zona fasciculata produces glucocorticoids like cortisol; and the zona reticularis secretes weak sex hormones, particularly dehydroepiandrosterone sulfate also known as DHEAS.

The adrenal medulla, on the other hand, secretes catecholamines including norepinephrine and epinephrine.

Because each hormone produces a different effect, a thorough history and physical examination can provide clues about which hormone is being produced by the tumor.

Alright, let’s discuss a patient with a cortisol hypersecreting adrenal adenoma. These patients may present with a history of fatigue, irritability, or lethargy; and they may report symptoms of depression or memory deficits, and possibly even weight gain.

Your physical exam might find evidence of Cushing syndrome, depending on the duration and severity of hypercortisolism.

These can include truncal obesity, purplish-red abdominal striae, bruising, acne, hirsutism, or muscle weakness. With these findings, consider hypercortisolism, and obtain labs to test for cortisol hypersecretion.