From the Guidelines
The management of adrenal collision tumors should prioritize a comprehensive approach, including complete hormonal assessment and high-quality imaging studies, with surgical resection recommended for tumors that are hormonally active, larger than 4-6 cm, or contain suspected malignant components, as suggested by the most recent guidelines 1.
Key Considerations
- Initial evaluation should include complete hormonal assessment to identify any functional components, such as Cushing syndrome, which can be caused by a benign adrenal tumor or a malignant adrenal tumor 1.
- High-quality imaging studies, such as contrast-enhanced CT, MRI, and possibly PET-CT, are essential to characterize the lesions and guide treatment decisions 1.
- Surgical resection is typically recommended for tumors that are hormonally active, larger than 4-6 cm, demonstrate concerning radiological features, or contain suspected malignant components, with laparoscopic adrenalectomy preferred when feasible 1.
- For patients with metastatic components, additional treatments such as chemotherapy, radiation therapy, or targeted therapies may be required based on the specific tumor types involved, as outlined in the ESMO-EURACAN clinical practice guidelines for diagnosis, treatment, and follow-up of adrenocortical carcinomas and malignant phaeochromocytomas 1.
Multidisciplinary Approach
- Multidisciplinary team involvement is essential, including endocrinologists, surgeons, oncologists, and radiologists, to optimize management decisions for these complex and rare tumors that contain two or more distinct neoplasms within the same adrenal mass 1.
- Regular imaging surveillance and hormonal monitoring should be performed postoperatively, with frequency determined by the tumor components and malignancy risk, to ensure timely detection of any recurrence or progression 1.
Treatment Options
- Medical management of hypercortisolism can be achieved with adrenostatic agents, such as ketoconazole and mitotane, with ketoconazole being the most commonly used due to its easy availability and relatively tolerable toxicity profile 1.
- Bilateral adrenalectomy may be recommended in certain cases, such as ectopic Cushing syndrome, to control symptoms and prevent further complications 1.
From the Research
Management Approach for Adrenal Collision Tumors
The management of adrenal collision tumors involves a combination of diagnostic imaging, functional workup, and surgical intervention.
- Diagnostic imaging plays a crucial role in characterizing the adrenal mass and identifying the presence of a collision tumor. Computed tomography (CT) and magnetic resonance imaging (MRI) are the primary imaging modalities used, with CT being less expensive and widely available, and MRI providing excellent tissue contrast and superior characterization 2.
- A functional workup is essential to determine if the adrenal mass is hormonally active, as some collision tumors may produce excess hormones, such as cortisol or aldosterone 3.
- Surgical intervention, typically adrenalectomy, is the primary treatment for adrenal collision tumors. Laparoscopic adrenalectomy is currently replacing open surgery as the standard surgical management of adrenal masses, offering a minimally invasive approach with reduced morbidity and mortality 4.
- The use of iodocholesterol scintigraphy and plasma steroid assays may not be reliable in excluding the diagnosis of adrenal metastasis in collision tumors, as these tests may be influenced by the presence of a benign adenoma component 5.
- MRI can demonstrate and enable characterization of the separate components of collision tumors within the adrenal gland, which can be crucial in planning and guiding subsequent percutaneous needle biopsy and patient care 6.
Key Considerations
- Adrenal collision tumors are rare and can produce unique diagnostic challenges for clinicians.
- A comprehensive diagnostic workup, including imaging and functional studies, is essential for accurate diagnosis and management.
- Surgical intervention, typically adrenalectomy, is the primary treatment for adrenal collision tumors, with laparoscopic adrenalectomy being the preferred approach.
- The presence of a collision tumor can be a pitfall of scintigraphy imaging and hormone assays, highlighting the importance of careful diagnostic evaluation 5.