What are the symptoms of an adrenal mass?

Symptoms of Adrenal Masses

Most adrenal masses are asymptomatic and discovered incidentally during imaging performed for unrelated reasons, but when symptomatic, they present with specific hormone-related manifestations depending on their functional status. 1

Clinical Presentation

Adrenal masses can present with various symptoms depending on their hormonal activity:

Hormone-Producing Masses

1. Hypercortisolism (Cushing's syndrome)

   • Weight gain and central obesity
   • Easy bruising
   • Severe hypertension
   • Diabetes
   • Proximal muscle weakness
   • Fatigue and depression
   • Sleep disturbances
   • Menstrual irregularities
   • Virilization
   • Fragility fractures 1

2. Primary Aldosteronism

   • Hypertension (often resistant to treatment)
   • Hypokalemia
   • Muscle cramping and weakness
   • Headaches
   • Intermittent paralysis 1

3. Pheochromocytoma

   • Headaches
   • Anxiety attacks
   • Sweating
   • Palpitations
   • Hypertension (often paroxysmal) 1

4. Androgen-Producing Tumors

   • Virilization in women
   • Hirsutism
   • Menstrual irregularities 1

Malignant Adrenal Masses

• Adrenocortical Carcinoma

  • Flank pain
  • Abdominal discomfort
  • Rapid onset of hormonal symptoms (hypercortisolism, virilization, feminization)
  • Weight loss
  • Abdominal fullness 1

• Metastatic Disease

  • Weight loss
  • Unexplained fevers
  • Symptoms related to primary malignancy 1

Important Clinical Considerations

Subclinical Hormone Production

Even though many adrenal masses are discovered incidentally and appear asymptomatic, a significant proportion show subclinical hormone production:

• 12-23% of patients with incidentalomas have detectable secretion of aldosterone, cortisol, or catecholamines 2
• Mild autonomous cortisol secretion (MACS) can occur without obvious clinical signs of Cushing's syndrome but may still contribute to health problems 3

Size and Symptom Correlation

• Larger adrenal masses (>4-5 cm) are more likely to be symptomatic and malignant 2
• Smaller lesions are usually benign but may still produce hormones subclinically 2, 1

Common Pitfalls in Diagnosis

1. Missing subclinical hormone production: Even "non-functioning" tumors may produce low levels of hormones that contribute to hypertension, diabetes, and osteoporosis 3

2. Overlooking pheochromocytoma: These can be life-threatening if not identified before surgery or biopsy due to potential catecholamine crisis 1

3. Attributing symptoms to other conditions: Vague symptoms like hypertension, weight gain, and fatigue may be incorrectly attributed to common conditions rather than an adrenal mass 1

Diagnostic Approach

When an adrenal mass is detected, a comprehensive hormonal evaluation is essential regardless of symptoms:

1. Cortisol assessment: 1-mg overnight dexamethasone suppression test (cutoff ≤50 nmol/L or ≤1.8 μg/dL) 1, 3

2. Catecholamine screening: Plasma free metanephrines or 24-hour urinary fractionated metanephrines 1

3. Aldosterone evaluation: Aldosterone-to-renin ratio (ARR >20 ng/dL per ng/mL/hr suggests hyperaldosteronism) 1

4. Androgen assessment: DHEAS and testosterone levels 1

Remember that even incidentally discovered adrenal masses without obvious symptoms require thorough evaluation for subclinical hormone production and malignancy risk assessment based on imaging characteristics.