What are the signs and symptoms of adrenal adenomas?

Signs and Symptoms of Adrenal Adenomas

Adrenal adenomas commonly present with signs and symptoms related to hormone excess (in approximately 60% of cases) or may be asymptomatic if non-functioning, with symptoms related to tumor burden appearing only in larger tumors. 1

Hormone-Related Presentations

Cortisol-Secreting Adenomas (Cushing Syndrome)

• Weight gain, particularly centripetal obesity
• Purple striae
• Buffalo hump and supraclavicular fat pad enlargement
• Proximal muscle weakness
• Hypertension
• Psychiatric disturbances
• Hirsutism
• Hyperglycemia
• Hypokalemia 1
• Patients may also have "Preclinical" or "Mild Autonomous Cortisol Secretion" (MACS) without overt Cushing's syndrome 2

Aldosterone-Secreting Adenomas (Primary Hyperaldosteronism)

• Hypertension (often resistant to treatment)
• Weakness
• Hypokalemia 1
• Elevated plasma aldosterone-to-renin ratio (usually >30) 1

Androgen-Secreting Adenomas

In women:

• Hirsutism
• Deepening of voice
• Oligo/amenorrhea 1
• Acne 3

In men:

• May be asymptomatic due to normal male androgenic features

Estrogen-Secreting Adenomas

In men:

• Gynecomastia
• Testicular atrophy 1

Non-Hormone Related Presentations

Asymptomatic/Incidental Finding

• Most commonly discovered incidentally during imaging for unrelated conditions 4
• Represent 3-4% of patients undergoing abdominal imaging 4

Symptoms Related to Tumor Size (Usually in Larger Tumors)

• Abdominal pain
• Back pain
• Early satiety
• Weight loss 1

Associated Comorbidities

Patients with hormone-producing adenomas, even those with mild autonomous cortisol secretion, often have:

• Hypertension (present in 7 of 8 patients with subclinical cortisol-producing tumors in one study) 5
• Obesity (present in 4 of 8 patients with subclinical cortisol-producing tumors) 5
• Type 2 diabetes or impaired glucose tolerance 5, 2

Important Diagnostic Considerations

1. All patients with adrenal masses should undergo:

   • Careful clinical assessment for symptoms of hormone excess 1
   • Plasma-free or urinary-fractionated metanephrines to rule out pheochromocytoma 1, 6
   • 1-mg overnight dexamethasone suppression test for cortisol excess 6, 2
   • Aldosterone-to-renin ratio if hypertension is present 6

2. Imaging characteristics that may help identify adenomas:

   • Benign adenomas typically have <10 Hounsfield Units on non-contrast CT 6

   • 60% contrast washout at 15 minutes suggests benign lesion 6

   • Signal intensity loss in opposed-phase images on MRI indicates benign adenoma 6

Clinical Pitfalls and Caveats

1. Don't miss subclinical hormone production: Even "non-functioning" adenomas may produce subtle hormone excess that contributes to metabolic complications 5, 2

2. Be aware of co-secreting tumors: Some adenomas can secrete multiple hormones simultaneously (e.g., cortisol and testosterone) 3

3. Consider adrenal insufficiency risk: Patients with cortisol-producing adenomas may develop temporary adrenal insufficiency after adrenalectomy 5

4. Don't assume all adenomas are benign: While most are benign, features such as size >4 cm, irregular margins, heterogeneous appearance, high attenuation (>10 HU), or poor contrast washout should raise suspicion for malignancy 6

5. Watch for improvement in comorbidities: After surgical removal of hormone-producing adenomas, improvements in hypertension, obesity, and diabetes control are often observed 5