Adrenal Tumors: Diagnosis, Endocrine Evaluation, and Surgical Management

Adrenal tumor care begins with precise hormonal evaluation, high-quality imaging, and coordinated multidisciplinary planning. Adrenal lesions encompass a broad spectrum of diseases ranging from benign incidental findings to hormonally active tumors and rare malignancies such as adrenal cortical carcinoma (ACC).

As a fellowship-trained surgical oncologist with expertise in complex retroperitoneal and endocrine tumor surgery, Dr. Geoffrey W. Krampitz provides individualized evaluation and surgical management of adrenal tumors with careful attention to endocrine physiology, oncologic principles, and operative safety.

Care is delivered through a multidisciplinary framework integrating surgical oncology, endocrinology, medical oncology, radiology, pathology, and genetics when appropriate, allowing treatment decisions to be guided by tumor biology, hormonal activity, imaging characteristics, and overall patient health.

Modern adrenal tumor management also requires familiarity with rare endocrine malignancies, hereditary cancer syndromes, and molecular drivers of adrenal tumor biology, particularly in patients with suspected adrenal cortical carcinoma.

Understanding the Adrenal Glands

The adrenal glands are paired endocrine organs located above each kidney. They regulate several critical physiologic processes including:

  • blood pressure regulation

  • electrolyte balance

  • metabolism

  • stress response

Each gland contains two distinct functional regions:

Adrenal Cortex — produces cortisol, aldosterone, and androgen precursors
Adrenal Medulla — produces catecholamines (epinephrine and norepinephrine)

Tumors may arise from either region and may be functional (hormone-producing) or nonfunctional.

Understanding both the endocrine physiology and oncologic biology of adrenal tumors is essential to determining the appropriate treatment strategy.

Types of Adrenal Tumors

Adrenal tumors encompass several distinct clinical entities.

Functional Adrenal Tumors

Hormone-producing tumors may cause recognizable endocrine syndromes including:

  • Primary hyperaldosteronism (Conn syndrome)

  • Cushing syndrome from cortisol excess

  • Pheochromocytoma from catecholamine overproduction

  • androgen or estrogen excess

These tumors require coordinated endocrine, anesthetic, and surgical management, as hormonal instability can influence perioperative safety.

Nonfunctional Adrenal Adenomas

Nonfunctional adrenal adenomas are commonly discovered incidentally during imaging performed for unrelated conditions.

Management depends on:

  • tumor size

  • imaging characteristics

  • interval growth

  • suspicion for malignancy

Many benign adenomas can be safely monitored with structured surveillance.

Adrenal Cortical Carcinoma (ACC)

Adrenal cortical carcinoma is a rare but aggressive endocrine malignancy requiring meticulous oncologic evaluation and surgical expertise.

Long-term outcomes depend heavily on complete tumor removal at the initial operation, emphasizing the importance of referral to experienced surgical programs.

Adrenal Metastases

The adrenal gland may also serve as a site of metastasis from other cancers, including:

  • lung cancer

  • renal cell carcinoma

  • melanoma

  • gastrointestinal malignancies

In carefully selected patients with isolated adrenal metastasis, surgical resection may provide durable disease control.

Clinical Presentation

Many adrenal tumors are discovered incidentally during imaging performed for unrelated conditions.

Hormone-producing tumors may present with symptoms such as:

  • difficult-to-control hypertension

  • palpitations or episodic headaches

  • unexplained weight gain or muscle weakness

  • easy bruising

  • hypokalemia

  • new-onset diabetes

Because symptoms may be subtle or nonspecific, comprehensive endocrine evaluation is essential when adrenal tumors are identified.

Diagnostic Evaluation

Evaluation of adrenal tumors requires both biochemical testing and high-resolution imaging.

Hormonal Testing

Evaluation may include:

  • plasma metanephrines (pheochromocytoma screening)

  • aldosterone-to-renin ratio

  • dexamethasone suppression testing for cortisol excess

  • androgen precursor testing when indicated

Endocrinology consultation is frequently integrated into care.

Imaging

High-resolution CT imaging evaluates:

  • tumor size

  • radiographic density and washout characteristics

  • local invasion

  • relationship to adjacent structures

MRI may be used in selected cases to further characterize indeterminate lesions.

When malignancy is suspected, additional staging imaging may be required.

Adrenal Cortical Carcinoma (ACC): Oncologic and Molecular Considerations

Adrenal cortical carcinoma is biologically complex and requires specialized oncologic management.

Staging and Pathology

ACC is staged using the ENSAT classification system, which incorporates:

  • tumor size and local invasion

  • lymph node involvement

  • presence of distant metastases

Pathologic evaluation includes:

  • Weiss criteria for malignancy assessment

  • Ki-67 proliferation index

  • margin status (R0 vs R1 resection)

  • capsular and vascular invasion

Preservation of tumor capsule integrity during resection is critical, as capsular disruption increases recurrence risk.

Molecular and Genetic Features

ACC frequently demonstrates characteristic molecular alterations including:

  • TP53 mutations, including association with Li-Fraumeni syndrome

  • CTNNB1 (β-catenin pathway) alterations

  • IGF2 overexpression

  • chromosomal instability patterns

In selected patients, germline genetic testing may be recommended to evaluate for inherited syndromes such as:

  • Li-Fraumeni syndrome

  • Lynch syndrome

Molecular profiling increasingly informs prognostic assessment, systemic therapy selection, and clinical trial eligibility.

Surgical Management

Adrenalectomy

Surgical removal of the adrenal gland is recommended when:

  • the tumor is hormonally active

  • imaging suggests malignancy

  • the lesion is large or demonstrates interval growth

  • isolated adrenal metastasis is appropriate for resection

The objective of surgery is complete tumor removal while preserving oncologic principles and endocrine stability.

Robotic and Open Adrenal Surgery

Modern adrenal surgery incorporates both robotic-assisted and open approaches, with operative strategy determined by tumor biology, anatomic complexity, and surgeon judgment.

Robotic Adrenalectomy

For appropriately selected tumors, robotic adrenalectomy may offer:

  • enhanced three-dimensional visualization

  • precise vascular dissection

  • improved dexterity in the confined retroperitoneal space

  • reduced postoperative discomfort and shorter hospital stay

Robotic platforms are particularly valuable in the deep retroperitoneal anatomy surrounding the adrenal gland.

Open Adrenalectomy

Open surgery may be preferred in selected situations involving:

  • locally invasive tumors

  • extensive vascular involvement

  • tumors requiring multivisceral resection

Importantly, tumor size alone is no longer considered an absolute indication for open surgery.

The decision to pursue robotic or open adrenalectomy depends on the surgeon’s ability to achieve:

  • complete en bloc tumor resection

  • negative surgical margins (R0 resection)

  • preservation of tumor capsule integrity

Oncologic principles always take precedence over operative platform.

Medical Preparation Before Surgery

Certain functional tumors require specialized preoperative preparation.

Pheochromocytoma

  • Requires alpha-adrenergic blockade and blood pressure optimization prior to surgery.

Cortisol-Producing Tumors

  • Require perioperative steroid management to prevent adrenal insufficiency.

Coordination among endocrinology, anesthesia, and surgical teams is essential.

Systemic and Adjuvant Therapy for ACC

In patients with high-risk or advanced adrenal cortical carcinoma:

  • Mitotane therapy may be recommended as adjuvant treatment

  • systemic chemotherapy may be incorporated in selected cases

Treatment decisions are guided by stage, Ki-67 index, and margin status and are individualized through multidisciplinary discussion.

Potential Risks of Adrenal Surgery

Adrenalectomy is a major retroperitoneal operation. Possible complications include:

  • bleeding

  • infection

  • blood pressure instability

  • hormonal fluctuations

  • injury to adjacent organs

Careful perioperative monitoring and experienced surgical technique help minimize risk.

Recovery After Surgery

Recovery varies depending on tumor type and surgical approach.

Patients undergoing minimally invasive adrenalectomy often return home within a few days and gradually resume activity. Hormonal follow-up and blood pressure monitoring are essential in functional tumors.

Multidisciplinary Endocrine Oncology Care

Adrenal tumor management frequently involves collaboration among:

  • surgical oncology

  • endocrinology

  • medical oncology

  • radiology and pathology

  • genetic counseling when appropriate

Complex adrenal tumors benefit from evaluation within multidisciplinary endocrine oncology programs experienced in managing rare adrenal diseases.

Summary

Adrenal tumors range from benign incidental findings to hormonally active lesions and rare malignancies such as adrenal cortical carcinoma.

Accurate endocrine evaluation, high-quality imaging, and thoughtful surgical planning are essential for safe and effective treatment.

When surgery is required, operative strategy is guided by tumor biology, endocrine physiology, and oncologic principles — with robotic techniques incorporated selectively and open surgery utilized when necessary to ensure complete tumor removal with preservation of tumor capsule integrity and negative margins.

Consultation and Referral

For Patients:
Individuals seeking evaluation for adrenal tumors — including adrenal incidentalomas, hormone-producing tumors, suspected adrenal cortical carcinoma, or adrenal metastases — may Request a Consultation to discuss individualized diagnostic evaluation and treatment strategy within a coordinated multidisciplinary framework.

For Referring Physicians:
Physicians wishing to refer a patient or discuss complex adrenal tumor management may visit For Physicians for direct referral pathways and coordinated multidisciplinary case review.