Adrenal metastases

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Ammu Susheela, M.D. [2]

Overview

The pathogenesis of adrenal metastases is characterized by metastases from renal cell carcinoma, melanoma, lung cancer, colorectal cancer, breast cancer and lymphoma. On gross pathology, a unilateral, small asymptomatic lesion is a characteristic finding of adrenal metastasis. Adrenal metastases must be differentiated from other diseases that cause tumors in adrenal gland such as nonfunctional adenoma, primary carcinoma in adrenal glands, adrenal cyst, and non-functional pheochromocytoma. Adrenal metastases are thought to be present in up to 27% of patients with known malignant epithelial tumors at autopsy. Symptoms of adrenal metastases may include dizziness, faintness, fatigue, weakness, and weight loss. CT is the imaging modality of choice for adrenal metastases. The mainstay of therapy for adrenal metastases is chemotherapy.

Pathophysiology

• Adrenal metastases occur secondary to hematogenous seeding of neoplastic cells from renal cell carcinoma, melanoma, lung cancer, colorectal cancer, breast cancer and lymphoma.
• On gross pathology, a unilateral, small asymptomatic lesion is a characteristic finding of an adrenal metastasis.

Differentiating Adrenal metastases from other Diseases

Adrenal metastasis must be differentiated from other adrenal tumors such as adrenocortical adenoma, adrenal metastasis, adrenal medullary tumors, and Cushing's syndrome.

Differential Diagnosis	Clinical picture	Imagings	Laboratory tests
Adrenocortical carcinoma	Mass effect symptoms Symptoms related to excess glucocorticoid Symptoms related to excess mineralocorticoid Symptoms related to excess androgen or estrogen secretion	Irregular shape Non-homogeneous density because of central areas of low attenuation due to tumor necrosis Tumor calcification Diameter usually >4 cm Unilateral location High unenhanced CT attenuation values (>20 HU) Non-homogeneous enhancement on CT with intravenous contrast Delay in contrast medium washout (10 minutes after administration of contrast, an absolute contrast medium washout of less than 50 percent) Hypointensity compared with liver on T1 weighted MRI and high to intermediate signal intensity on T2 weighted MRI High standardized uptake value (SUV) on FDG-PET-CT study Evidence of local invasion or metastases	Adrenal androgens (DHEAS) Androstenedione Bioavailable testosterone should be measured in every patient. 17-hydroxyprogesterone Serum estradiol in men and postmenopausal women Cortisol level Fasting serum cortisol at 8 AM following a 1 mg dose of dexamethasone at bedtime
Adrenal adenoma	Symptoms related to excess glucocorticoid Symptoms related to excess mineralocorticoid	Round, homogeneous with sharp margination Unilateral with diameter less than 4 cm Low unenhanced CT attenuation values (<10 HU) Rapid contrast medium washout after administration of contrast An absolute contrast medium washout of more than 50 percent Chemical shift: evidence of lipid on MRI Isointensity with liver on both T1 and T2 weighted MRI sequences	Cortisol level Fasting serum cortisol at 8 AM following a 1 mg dose of dexamethasone at bedtime Renin (PRA) or plasma renin concentration (PRC): very low in patients with primary aldosteronism, usually less than 1 ng/mL per hour for PRA and usually undetectable for PRC
Cushing's syndrome	Rapid weight gain, particularly of the trunk and face with limbs sparing (central obesity) Proximal muscle weakness A round face often referred to as a "moon face" Excess sweating Headache	Imaging may show mass if presents	24-hour urine cortisol Midnight salivary cortisol Low-dose dexamethasone suppression test; high cortisol level after the dexamethasone test is suggestive of hypercortisolism.
Pheochromocytoma	Palpitations especially in epinephrine-producing tumors. Anxiety often resembling that of a panic attack Sweating Headaches occur in 90 % of patients. Paroxysmal attacks of hypertension but some patients have normal blood pressure. It may be asymptomatic and discovered incidentally after screening for MEN patients.	Increased attenuation on non-enhanced CT (>20 HU) Increased mass vascularity Delay in contrast medium washout (10 minutes after administration of contrast, an absolute contrast medium washout of less than 50 percent) High signal intensity on T2 weighted MRI Cystic and hemorrhagic changes Variable size and may be bilateral	Plasma fractionated metanephrines  24-hour urinary fractionated metanephrines
Adrenal metastasis	Symptoms and signs of primary malignancy especially lung cancer General constitutional symptoms: Fever Fatigue Weight loss	Irregular shape and non-homogeneous nature Tendency to be bilateral High un-enhanced CT attenuation values (>20 HU) and enhancement with intravenous contrast on CT Delay in contrast medium washout (10 minutes after administration of contrast, an absolute contrast medium washout of less than 50 percent) Isointensity or slightly less intense than the liver on T1 weighted MRI and high to intermediate signal intensity on T2 weighted MRI (representing an increased water content) Elevated standardized uptake value on FDG-PET scan

Epidemiology and Demographics

• Adrenal metastases are thought to be present in up to 27% of patients with known malignant epithelial tumors at autopsy.

Natural History, Complications and Prognosis

• If left untreated, 20-35% of patients with cancer may progress to develop adrenal metastases.
• Complications of adrenal metastases include central necrosis with adrenal hemorrhage and paraneoplastic leukemoid reaction.

Diagnosis

Symptoms

• Symptoms of adrenal metastases may include the following:

• Dizziness
• Faintness
• Fatigue
• Weakness
• Weight loss

Physical Examination

• Patients with adrenal metastases usually appear cachectic.
• Physical examination may be remarkable for:

• Abdominal mass

Laboratory Findings

• There are no specific laboratory findings associated with adrenal metastases.

Imaging Findings

• CT is the imaging modality of choice for adrenal metastases.
• On CT, adrenal metastases may demonstrate less than 50% washout.
• On MRI, adrenal metastases may demonstrate:

• T1: usually exhibit low signal intensity
• T2: usually exhibit high signal intensity
• T1 C+ (Gd): usually has progressive enhancement after administration of contrast material.

Treatment

Medical Therapy

• The mainstay of therapy for adrenal metastases is chemotherapy.

Surgery

• Adrenalectomy in conjunction with chemotherapy is the most common approach to the treatment of adrenal metastases if primary disease is well controlled and the only site of metastasis is the adrenal gland.

Prevention

• There are no primary preventive measures available for adrenal metastases.