Nodular diseases of the adrenal gland

What is it?

Diagnostics and treatment of various adrenal abnormalities is in the field of endocrinology; however, in many cases pathologies such as pheochromocytoma, hyperaldosteronism or Cushing's syndrome are treated by complete surgical removal of the affected adrenal gland. Adrenal nodular pathology includes several types of lesions; any expansive adrenal mass must be studied to assess its characteristics and potential malignancy.

  • Adrenal cortex may be affected by adenomas, carcinomas or nodular hyperplasia. They can be non-secreting or secrete hormones and therefore cause peculiar clinical manifestations, such as Cushing's syndrome (in the case of increased glucocorticoid secretion) and hyperaldosteronism (increased aldosterone secretion).
  • The central part of the gland, known as the medulla, may contain a pheochromocytoma or other neoplasm of nervous origin. Pheochromocytoma is a rare adrenal medulla tumour that secretes catecholamines and causes 0.1% of hypertension cases.

Which are the symptoms?

Whether an adrenal mass is symptomatic or not depends on its ability to release hormones into the systemic circulation. Most adrenal nodular lesions are not secreting and are sometimes discovered by the patient during diagnostic examinations for other problems. In these cases, the nodular lesions are called 'incidentalomas' with the prevalence of 1-6% in adult population.

In the case of secreting lesions, symptoms depend on the type of hormone secreted:

In most cases, patients have symptoms associated with increased secretion of glucocorticoids. These patients are at higher risk of hypertension, obesity, diabetes, dyslipidaemia, osteopenia and osteoporosis. In the most obvious cases (rare now) the condition can escalate to Cushing's syndrome, with the characteristic dorsal hump, moon-shaped face and striae rubra.

In cases of hyperaldosteronism, on the other hand, the typical symptom is increased blood pressure, responsible for 1% of hypertension cases. Headache, hypokalemia and asthenia may also occur.

Instead, pheochromocytoma may be asymptomatic or may include symptoms mainly of the cardiovascular system, such as drug-resistant hypertension, tachycardia, significant headache, pallor, and sweating.

  • No symptoms
  • Hypertension
  • Headache
  • Obesity
  • Asthenia
  • Hypokalemia
  • Diabetes mellitus
  • Moon facies
  • Striae rubra
  • Dorsal tubercle
  • Pallor
  • Sweating

How is it diagnosed?

In case of a nodal lesion, its appearance on imaging and hormonal profile must be assessed to better characterise the lesion. In particular:

  • A CT scan is required to check the size, shape, density by Hounsfield and other morphological signs of the lesion. Other diagnostic tests, such as MRI and PET, may also be useful.
  • Hormone profile assessment is also necessary to understand the nature of the nodal lesion. Depending on the clinical suspicion, a screening examination and subsequent confirmatory examination are carried out.

Thus, the combination of the patient's clinical symptoms, the appearance of the lesion on imaging and the hormonal profile allows correct diagnosis and a decision on further patient's management.

Suggested exams

How is it treated?

Treatment of nodular diseases of the adrenal gland depends on many factors, such as the patient's symptoms, appearance on imaging and hormonal profile. In particular: - If the lesions are secreting, pheochromocytoma requires surgical treatment, which should also be considered in cases of hypercortisolism and hyperaldosteronism. In case of non-secreting lesions, no treatment is required except for progressive symptoms indicating the development of hormone secretion.

  • In benign-looking masses (e.g. <4 cm diameter, attenuation <10 by Hounsfield, contrast washout >40-60%), treatment is not required if the patient's symptoms do not progress, indicating that hormonal secretion is developing.
  • In cases of malignancy (e.g. diameter >4 cm, attenuation >10 by Hounsfield, contrast washout <40-60%), excision of the adrenal gland should be considered. Alternatively, follow-up after 6-12 months by new imaging diagnostics to monitor the progression of the pathology could be considered.
  • Should metastases be suspected, a biopsy may be considered if histopathological confirmation would alter the patient's diagnostic and therapeutic course.

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