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Adrenal lesions

The adrenal glands make cortisol, aldosterone, adrenaline and noradrenaline. A growth on an adrenal gland may make too much of one of these hormones, be suspicious for cancer, or be completely benign. Which bucket it falls into is what drives whether surgery is needed.

Functioning (hormone-producing) tumours

  • Phaeochromocytoma - rare, catecholamine-producing tumour of the adrenal medulla. Causes paroxysmal hypertension, headache, sweating and palpitations. Requires alpha blockade before surgery.
  • Conn's syndrome (primary aldosteronism) - aldosterone-producing adenoma causing hypertension and, sometimes, hypokalaemia. Surgery is curative for unilateral disease.
  • Cushing's syndrome - cortisol-producing adenoma causing weight gain, hyperglycaemia, skin changes and osteoporosis. Surgery is curative for the adrenal source.
  • Virilising or feminising tumours - rare sex-steroid-producing tumours.

Non-functioning masses and incidentalomas

Adrenal incidentalomas - masses found on imaging performed for another reason - are very common with modern CT. Most are benign adenomas. The decision to operate depends on size, imaging features and serial growth:3

  • Functioning lesions on hormone screening - operate.
  • Mass > 4 cm or with concerning imaging features - operate.
  • Mass that grows on serial imaging - operate.
  • Small, benign-appearing, non-functioning adenomas - observe.

Primary adrenal cancer and metastases

  • Adrenocortical carcinoma - rare, often large at presentation, needs complete surgical resection as the main curative treatment.
  • Adrenal metastases - most common primaries are lung, renal, breast, melanoma. Surgery is considered when the primary is controlled and the metastasis is isolated.

Workup

Every adrenal mass is assessed with:

  • Dedicated adrenal CT (or MRI with chemical shift) for imaging characterisation.
  • Plasma free metanephrines (or 24-hour urinary fractionated metanephrines) - to exclude phaeochromocytoma.
  • Overnight 1 mg dexamethasone suppression test - for autonomous cortisol secretion.
  • Aldosterone-to-renin ratio - especially if hypertensive or hypokalaemic.

Role of robotic surgery

When surgery is indicated, robotic adrenalectomy is an option for most tumours, particularly those that are larger or right-sided. Dedicated adrenal surgery information is on adrenalsurgery.com.au.

Considering robotic surgery?

You can request a second opinion on imaging, staging and treatment options before you decide. General information only; not individual medical advice.

Request a second opinion Call 02 8382 6980