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Reasons for Adrenalectomy

Hyperfunctional Tumors

One common reason a person may need to have an adrenalectomy is a hyperfunctional tumor. This kind of tumor inappropriately overproduces hormones.

There are three main types of hyperfunctional tumors: pheochromocytomasaldosteronomas, and cortisol-producing adenomas. Each is described in detail below.

1. Pheochromocytoma

This is a type of tumor originating from the adrenal medulla. These tumors secrete excessive amounts of catecholamines, including epinephrine (adrenaline) and norepinephrine.

  • Signs and symptoms of pheochromocytoma:
  • Severe hypertension (high blood pressure)
  • Tachycardia (increased heart rate)
  • Palpitations
  • Cardiac arrhythmias (irregular heartbeat)
  • Anxiety attacks
  • Weight loss
  • Sweating
  • Headaches

Some statistics:

  • 30% of pheochromocytomas are hereditary (familial).
  • 10% involve both adrenal glands (bilateral).
  • 10% occur outside the adrenal gland (paragangliomas).
  • 10% are malignant (cancerous).

Diagnosis is made by blood and/or urine tests that measure catecholamines and metanephrines. Once the biochemical diagnosis has been made, an imaging study will be used to determine the location of the tumor (i.e., right vs. left adrenal gland, inside vs. outside the adrenal gland). Imaging options include CT, MRI, and MIBG scans.

The treatment for pheochromocytoma is adrenalectomy (removal of the affected adrenal gland). Prior to your operation, you will be placed on an antihypertensive medication for 1-3 weeks. This helps prevent unstable blood pressure during surgery.

2. Aldosteronoma (Aldosterone-producing Adrenal Adenoma)

Aldosterone-producing adrenal adenomas (often referred to simply as “aldosteronomas”) are tumors originating from the glomerulosa zone of the adrenal cortex. They produce too much aldosterone, resulting in a condition known as primary hyperaldosteronism.

Signs and symptoms of primary hyperaldosteronism:

  • Hypertension (high blood pressure)
  • Hypokalemia (low potassium levels)
  • Muscle cramping
  • Muscle weakness
  • Polydipsia (increased thirst)
  • Polyuria (increased urinary frequency)
  • Nocturia (increased nighttime urination)

Diagnosis is made by blood tests that measure aldosterone and renin levels. If these tests are suggestive of disease, a confirmatory test with salt loading will be performed.

Once the diagnosis is established, a CT/MRI adrenal protocol will be performed to determine the location of the tumor. In most cases, adrenal vein sampling will also be performed to verify that the lesion seen on the imaging study is definitely the one causing the hormonal hypersecretion. This test is performed in Interventional Radiology and involves placing a small catheter in a groin vein to measure the aldosterone levels in each adrenal vein.

Note: Another condition that can cause primary hyperaldosteronism is unilateral hyperplasia of the adrenal gland. Adrenal vein sampling, as described above, can be used to determine whether the patient has a unilateral hyperplasia (which can be cured by adrenalectomy) or bilateral hyperplasia (which is best treated with medicine.)

3. Cortisol-producing Adrenal Adenoma

These tumors originate in the fasciculata zone of the adrenal cortex and cause excessive production of cortisol, which leads to hypercortisolism (Cushing Syndrome).

Signs and symptoms of hypercortisolism:

  • Fatigue
  • Depression
  • Hypertension (high blood pressure)
  • Central (abdominal) obesity and general weight gain
  • Glucose intolerance (diabetes)
  • Osteoporosis (weak bones)
  • Muscle weakness
  • Ecchymosis (bruising easily)
  • Acne
  • Hirsuitism (excessive hair
  • Menstrual irregularities

Diagnosis is made with blood, urine, or salivary tests that measure cortisol levels. If these are suggestive of disease, a confirmatory test will be performed (dexamethasone suppression test).

Once the diagnosis is established, a CT/MRI adrenal protocol will be performed to determine the location of the tumor. The adrenal gland where the tumor is located will be surgically removed.

After the operation, you will need to take steroids until the remaining gland restarts its function. (This gland, while capable of producing cortisol, has been "asleep" because the body has been signaling it that cortisol levels were high.)

Incidentalomas are tumors in the adrenal gland incidentally found by an imaging study performed for some other reason. Many of these tumors do not require any surgery or treatment, but once discovered need to be carefully evaluated to determine the most appropriate management.

Evaluation of these tumors involves several components:

  1. Investigation of whether the tumor is secreting excessive amounts of a particular hormone. This is done by measuring hormone levels in blood and/or urine (cathecholamines, cortisol, aldosterone).
  2. Assessment of whether the tumor has a malignant (cancerous) appearance or not. Imaging studies such as CT scans and MRIs help make this determination by assessing tumor size (larger tumors are more likely cancerous) and other imaging characteristics that are worrisome for cancer.
  3. Determination of whether it is a metastatic lesion (cancer that originated elsewhere in the body and spread to the adrenal glands). This is done by evaluating prior medical history.

Further workup and management will depend on the results obtained on 1, 2 and 3.

The risk of an incidentally found adrenal tumor being an ACC is related to the size of the tumor:
  • 4-5% for tumors less than 4 cm in size.
  • Up to 10% for tumors 4-6 cm in size.
  • Greater than 25% in tumors greater than 6 cm in size.

The primary treatment and the only chance for cure for ACC is complete resection (surgical removal) of the tumor within the adrenal gland, as well as all surrounding structures that may have been invaded by the cancer. Adjuvant chemotherapy and radiation may be used in some patients.

Because of the aggressive nature of this type of cancer, it is important that patients with ACC (or even those suspected of having ACC) are evaluated and treated quickly and by physicians who are experienced with treating this rare cancer. Here at University of Colorado, we have a multidisciplinary team dedicated to treating patients with ACC. This team includes endocrine surgeons, endocrinologists, and medical and radiation oncologists.

Adrenocortical carcinoma (ACC) is a rare malignancy of the adrenal glands. ACC tumors are often quite large by the time they cause any symptoms.

Adrenal metastases are cancers that originated elsewhere in the body and spread to the adrenal gland.

Tumors that commonly metastasize to the adrenals include carcinomas of the:

  • Lung
  • Skin (melanoma)
  • Breast
  • GI tract (esophagus, stomach, colon)
  • Kidney
  • Pancreas
  • Liver
  • Ovary

In most patients with adrenal metastases, the source of the primary cancer is already known. Metastatic cancer to the adrenal without a known primary cancer is extremely rare.

When an adrenal nodule develops in a patient with a known history of cancer, it is important to determine whether the nodule is an adrenal metastasis or just a coincidental benign adrenal nodule. PET scans and FNA (fine-needle aspiration) can help make this determination. The probability of the  nodule being a metastasis is approximately 50%.

Unfortunately, many patients with adrenal metastases have multiple other sites of metastatic disease, so surgery to remove the adrenal tumor would not be beneficial. On the other hand, this type of surgery may be a good choice if (A) the tumor is causing pain or other symptoms, or (B) the adrenal metastasis is the only known remaining site of cancer.

This information is provided by the Department of Surgery at the University of Colorado School of Medicine. It is not intended to replace the medical advice of your doctor or healthcare provider. Please consult your healthcare provider for advice about a specific medical condition.


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