Adrenal tumor

Disease Description (Causes and Symptoms)

• Definition summary: An adrenal tumor is a tumor that develops in the adrenal gland (the adrenal cortex or adrenal medulla). Histologically, it resembles normal adrenal cells but is a lesion that may grow autonomously or secrete hormones. Most are benign or nonfunctional tumors, but functional tumors (excess hormone secretion) and malignant tumors (adrenocortical carcinoma) can also occur.
• Causes/pathophysiology: The cause is unknown in most cases. Adrenal cortical tumors cause symptoms through excess secretion of cortisol, aldosterone, or androgens, while adrenal medullary (chromaffin) tumors (e.g., pheochromocytoma) cause symptoms due to excess catecholamines (epinephrine and norepinephrine). If a functional tumor is present, the function of the normal contralateral adrenal gland may be suppressed.
• Main symptoms (vary depending on functionality)
  • Excess adrenal cortical steroids: hypertension, skeletal weakness (muscle weakness, osteoporosis), worsening diabetes, weight changes (gain or loss), Cushing syndrome (abdominal obesity, skin changes, etc.), virilization (deepening of the voice, hirsutism of the face and body), excessive breast development in women or gynecomastia in men, etc.
  • Excess adrenal medullary catecholamines: sweating, palpitations, elevated blood pressure (intermittent or persistent), anxiety, abdominal pain, etc.
  • Nonfunctional tumors: mostly asymptomatic and incidentally discovered during health screenings or imaging tests performed for other reasons
• Clinical considerations: Tumor size (surgery is generally considered based on a 4–6 cm threshold), imaging findings suggestive of malignancy, and whether hormones are being secreted determine the direction of evaluation and treatment

Treatment Methods

• Diagnostic approach
  • Hormone testing: Blood tests (cortisol, ACTH, aldosterone and renin, sex hormones, electrolytes, etc.), 24-hour urine tests (catecholamines, metanephrines, cortisol), or a low-dose dexamethasone suppression test, etc.
  • Imaging tests: CT (dedicated adrenal CT), MRI (particularly when malignancy or an adrenal medullary lesion is suspected), ultrasonography, and, if necessary, nuclear medicine tests (e.g., MIBG, PET)
• Conservative management (observation)
  • If the tumor is nonfunctional, has no radiologic signs of malignancy, and is small (generally <4–5 cm), it is monitored with regular imaging (e.g., CT/MRI every 6–12 months) and hormone tests
• Surgical treatment
  • Indications: Functional tumors (hormone secretion), imaging findings suspicious for malignancy, or size (generally ≥4–6 cm or enlarging tumors)
  • Methods: Laparoscopic adrenalectomy (for small lesions, with faster postoperative recovery) or open surgery (for large tumors or suspected invasion). During left or right adrenalectomy, there is a risk of injury to adjacent organs (the liver, spleen, kidney, inferior vena cava, etc.).
  • Preoperative preparation: In cases of pheochromocytoma (pheochrome), blood pressure must be stabilized preoperatively with sufficient α-blockade (e.g., phenoxybenzamine), followed by use of a β-blocker; for cortisol-secreting tumors, a plan for steroid supplementation is needed to prepare for temporary adrenal insufficiency after surgery
• Medication and adjunctive treatment
  • When adrenocortical carcinoma is suspected or confirmed: Standard medications such as adrenocorticotoxin (mitotane), and systemic chemotherapy/radiation therapy may be considered
  • Pheochromocytoma (catecholamine-secreting tumor): Control of blood pressure and pulse (α-blockers, and β-blockers if necessary)
• Postoperative management
  • Monitoring for hormone deficiency (adrenal insufficiency) and, if necessary, steroid replacement therapy (to prevent acute adrenal insufficiency)
  • Monitoring for complications: bleeding, infection, injury to adjacent organs, pulmonary complications, fluctuations in blood pressure, etc.
• Lifestyle management and precautions
  • Actively manage coexisting conditions such as hypertension, diabetes, and osteoporosis
  • Regular hormone follow-up tests are necessary even after resection of a functional tumor
  • If sudden weakness, hypotension, vomiting, or similar symptoms occur after surgery, visit a medical institution immediately (suspected adrenal insufficiency)

Checklist Before an Outpatient Visit (Including Example Questions)

• Items to prepare
  • A list of all medications and supplements currently being taken (including steroids, antihypertensive drugs, antidepressants, antipsychotics, etc.)
  • Previous test results (blood tests, imaging (CT/MRI) images or reports)
  • A record of symptom changes (when symptoms began, frequency, severity; blood pressure and heart rate measurements are useful if available)
  • Surgical history and family history (adrenal disease and hereditary syndromes: MEN2, VHL, NF, etc.)
• Medication-related precautions before testing
  • Certain medications (sympathomimetics, some antidepressants, antipsychotics, etc.) may affect catecholamine/metanephrine testing, so consult the treating physician to determine whether temporary discontinuation is necessary
  • If taking steroids, they may affect cortisol test results → inform the medical team in advance
• Items to show the doctor during the outpatient visit
  • Recent imaging (if possible, bring it saved on a CD), recent blood pressure records, and a symptom diary

Examples of General Questions to Ask the Doctor

• "How should the test results confirming whether this tumor is functional (and which hormones it is overproducing) be interpreted?"
• "What are the standard treatment options for this disease, and what are the risks and benefits of each?"
• "If surgery is necessary, which method is recommended—laparoscopy or open surgery—and approximately how long is the recovery period?"
• "Will hormone replacement be necessary after surgery, and if so, how long will I need to take it?"
• "At what intervals and for how long should follow-up tests (imaging and hormones) be performed?"

Examples of Disease-Specific Questions

• If a functional tumor is suspected:
  • "Which hormone was elevated in my test results, and how should complications caused by it (such as hypertension, diabetes, and fracture risk) be managed?"
• If pheochromocytoma (an adrenal medullary tumor) is suspected or confirmed:
  • "Which medications should I take to control my blood pressure and heart rate before surgery, when should I start them, and at what dosage? Which medications should I stop or avoid before surgery?"
• If adrenocortical carcinoma (malignancy) is suspected:
  • "Please explain whether additional anticancer medication (e.g., mitotane) or radiation therapy is needed in addition to surgery, as well as the prognosis and follow-up plan."