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Nonfunctional
adrenal masses are space-occupying lesions of the adrenal glands
that have no hormonal activity. Symptoms, signs, and treatment depend
on the nature and size of the mass.
The most common nonfunctioning adrenal mass in adults is an adenoma (50%), followed by carcinomas and metastatic tumors. Cysts and lipomas make up most of the remainder. However, the precise proportions depend on the clinical presentation. Masses discovered on incidental screening are usually adenomas. Less commonly, in neonates, spontaneous adrenal hemorrhage may produce large adrenal masses, simulating neuroblastoma or Wilms' tumor. In adults, bilateral massive adrenal hemorrhage may result from thromboembolic disease or coagulopathy. Benign cysts are observed in elderly patients and may be due to cystic degeneration, vascular accidents, lymphomas, bacterial infections, fungal infections (eg, Histoplasmosis), or parasitic infestations (eg, Echinococcus). Hematogenous spread of TB organisms may cause adrenal masses. A nonfunctional adrenal carcinoma produces a diffuse and infiltrating retroperitoneal process. Hemorrhage can occur, producing adrenal hematomas.
Symptoms
and Signs
Most patients are asymptomatic. With any adrenal mass, adrenal insufficiency is rare unless both glands are involved.
The major signs of bilateral massive adrenal hemorrhage are abdominal pain, falling Hct, signs of acute adrenal failure, and suprarenal masses on CT or MRI. TB of the adrenals may cause calcification and Addison's disease. Nonfunctional adrenal carcinoma usually manifests as metastatic disease and may therefore not be amenable to surgery, though mitotane may afford chemotherapeutic control when used with supportive exogenous corticosteroids.
Diagnosis
Nonfunctional adrenal masses are usually found incidentally during tests such as CT or MRI conducted for other reasons. Nonfunctionality is established clinically and confirmed by adrenal hormonal measurements (see Adrenal Disorders: Cushing's Syndrome). (See also the NIH
Consensus Statement on Management of the Clinically Inapparent Adrenal
Mass.) If metastatic disease is possible, fine-needle biopsy can be diagnostic but is contraindicated if adrenal carcinoma is strongly suspected.
Treatment
If the tumor is solid, of adrenal origin, and > 4 cm, it should be excised, because biopsy cannot always distinguish benign from malignant tumors.
Tumors 2 to 4 cm in diameter are a particularly difficult clinical problem. If scanning does not suggest cancer and hormonal function does not seem altered (eg, normal electrolytes and catecholamines, no evidence of Cushing's syndrome), it is reasonable to reevaluate periodically, usually up to 4 yr. If no progression is seen by then, further follow-up is unnecessary. However, many of these tumors secrete cortisol in quantities too small to produce symptoms, and whether they would eventually produce symptoms and morbidity if untreated is unclear. Most clinicians merely observe patients with these tumors.
Adrenal adenomas < 2 cm require no special treatment but should be observed for growth or development of secretory function (such as by looking for clinical signs and periodically measuring electrolytes).
Last full review/revision November 2007 by Ashley B. Grossman, MD
Content last modified November 2007
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