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Nonfunctional Adrenal Masses


Ashley B. Grossman

, MD, University of Oxford; Fellow, Green-Templeton College

Last full review/revision Sep 2020| Content last modified Sep 2020
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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 cause large adrenal masses, simulating neuroblastoma Neuroblastoma Neuroblastoma is a cancer arising in the adrenal gland or less often from the extra-adrenal sympathetic chain, including in the retroperitoneum, chest, and neck. Diagnosis is confirmed by biopsy... read more or Wilms tumor Wilms Tumor Wilms tumor is an embryonal cancer of the kidney composed of blastemal, stromal, and epithelial elements. Genetic abnormalities have been implicated in the pathogenesis, but familial inheritance... read more . In adults, bilateral massive adrenal hemorrhage may result from thromboembolic disease or coagulopathy, whether disease- or drug-related.

Benign cysts are observed in older patients and may be due to cystic degeneration or vascular accidents. Lymphomas, bacterial infections, fungal infections (eg, histoplasmosis Histoplasmosis Histoplasmosis is a pulmonary and hematogenous disease caused by Histoplasma capsulatum; it is often chronic and usually follows an asymptomatic primary infection. Symptoms are those of pneumonia... read more Histoplasmosis ), or parasitic infestations (eg, due to Echinococcus) may also manifest with adrenal masses, sometimes bilateral. Hematogenous spread of Mycobacterium tuberculosis may cause adrenal masses. A nonfunctional adrenal carcinoma causes a diffuse and infiltrating retroperitoneal process. Hemorrhage can occur, causing adrenal hematomas.

Symptoms and Signs of Nonfunctional Adrenal Masses

The major signs of bilateral massive adrenal hemorrhage are abdominal pain, falling hematocrit, signs of acute adrenal failure, and suprarenal masses on CT or MRI. Tuberculosis of the adrenals may cause calcification and Addison disease Addison Disease Addison disease is an insidious, usually progressive hypofunctioning of the adrenal cortex. It causes various symptoms, including hypotension and hyperpigmentation, and can lead to adrenal crisis... read more Addison Disease . Nonfunctional adrenal carcinoma usually manifests as invasive or metastatic disease.

Diagnosis of Nonfunctional Adrenal Masses

  • Adrenal hormone measurements

  • Fine-needle biopsy

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 also the ACR Appropriateness Criteria on Incidentally Discovered Adrenal Mass and AACE and AAES Medical Guidelines for the Management of Adrenal Incidentalomas.)

If metastatic or infectious disease is possible, fine-needle biopsy can be diagnostic but is contraindicated if there is suspicion of adrenal carcinoma (to avoid spread of tumor) or pheochromocytoma (to avoid precipitating acute hypertension).

Treatment of Nonfunctional Adrenal Masses

  • Sometimes excision, depending on size and/or imaging results

  • Periodic monitoring

Although new imaging modalities (eg, in-phase and out-of-phase MRI) may be diagnostic, if the tumor is solid, of adrenal origin, and > 4 cm, it should usually be excised unless the imaging characteristics are clearly benign.

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 metanephrines, no evidence of Cushing syndrome), it is reasonable to reevaluate periodically with imaging studies, usually for 1 to 2 years. If no progression is seen by then, further follow-up is unnecessary. However, many of these tumors secrete cortisol in quantities too small to cause symptoms, and whether they would eventually cause symptoms and morbidity if untreated is unclear. Most clinicians merely observe patients with these tumors, but clinicians should consider removal of these tumors if there is significant cortisol secretion.

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).

Nonfunctional adrenal carcinoma that has metastasized is not amenable to surgery, though mitotane plus corticosteroids may help control symptoms of hypercortisolism.

More Information

The following are some English-language resources that may be useful. Please note that THE MANUAL is not responsible for the content of these resources.

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Secondary Adrenal Insufficiency
Secondary adrenal insufficiency is adrenal hypofunction due to lack of adrenocorticotropic hormone (ACTH). Most of the symptoms and signs of this condition are similar to those of Addison disease. Which of the following symptoms and signs is present in patients with secondary adrenal insufficiency but not in patients with Addison disease?
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