What is the treatment for adrenal gland thickening?

Treatment of Adrenal Gland Thickening

The treatment of adrenal gland thickening depends entirely on the underlying etiology—first establish whether the thickening represents bilateral hyperplasia, adenoma, carcinoma, or other pathology through CT imaging and hormonal workup, then treat the specific cause accordingly. 1

Initial Diagnostic Approach

The term "adrenal gland thickening" is non-specific and requires systematic evaluation before treatment can be determined 2, 3:

• Obtain CT imaging with adrenal protocol to characterize the lesion(s), assess for unilateral vs bilateral involvement, measure Hounsfield units on unenhanced CT (>10 HU suggests malignancy), and evaluate contrast washout patterns 1
• Perform comprehensive hormonal evaluation including 1 mg dexamethasone suppression test for cortisol excess, plasma aldosterone-to-renin ratio for hyperaldosteronism, and plasma/urinary metanephrines for pheochromocytoma 1
• Measure 21-hydroxylase autoantibodies if adrenal insufficiency is suspected to identify autoimmune etiology 1

Treatment Based on Specific Diagnosis

Bilateral Adrenal Hyperplasia with Hypercortisolism

• Medical management with ketoconazole (400-1200 mg/day) or mitotane is the primary treatment when cortisol production is symmetric on adrenal vein sampling 1
• Bilateral laparoscopic adrenalectomy is recommended if medical management fails or for severe cases, followed by lifelong glucocorticoid and mineralocorticoid replacement 1
• If cortisol production is asymmetric on adrenal vein sampling, unilateral adrenalectomy of the most active side with postoperative corticosteroid supplementation 1

Bilateral Adrenal Hyperplasia with Hyperaldosteronism

• Medical management with spironolactone or eplerenone for hypertension and hypokalemia is recommended 1
• Surgery is not indicated for bilateral disease 1
• Adrenal vein sampling should be performed to distinguish unilateral adenoma from bilateral hyperplasia before considering surgery, except in patients <40 years with unilateral imaging findings 1

Unilateral Adenoma

• Laparoscopic adrenalectomy is recommended for functioning adenomas (aldosterone-producing or cortisol-secreting) when the patient is a surgical candidate 1
• For aldosterone-secreting adenomas, confirm lateralization with adrenal vein sampling before surgery 1
• Postoperative corticosteroid supplementation is required for cortisol-secreting adenomas until HPA axis recovery 1

Suspected Adrenal Carcinoma

• Immediate surgical resection with locoregional lymphadenectomy is the mainstay of treatment for localized disease 1
• Use laparoscopic/robotic approach for smaller contained masses; open approach for larger invasive tumors 1
• Adjuvant mitotane is recommended for incomplete resection (R1, Rx) or high-risk features (Ki67>10%) 1
• Adjuvant radiotherapy to tumor bed may be considered for R1/Rx resections 1
• Never perform biopsy of potentially resectable primary adrenal tumors—it is potentially harmful and not informative 1

Primary Adrenal Insufficiency (Addison's Disease)

If thickening represents adrenal destruction or infiltration causing insufficiency 1:

• Hydrocortisone 15-25 mg daily in split doses (first dose immediately after waking, last dose ≥6 hours before bedtime) 1
• Fludrocortisone 50-200 µg daily as single dose for mineralocorticoid replacement 1, 4
• Patients should wear medical alert identification and carry emergency hydrocortisone for self-injection 1
• For adrenal crisis: immediate IV/IM hydrocortisone 100 mg bolus, followed by 100 mg every 6-8 hours, plus 1 L/hour isotonic saline initially 1

Critical Pitfalls to Avoid

• Do not assume bilateral thickening is benign—it may represent metastases, lymphoma, hemorrhage, or infiltrative disease requiring CT-guided biopsy only after pheochromocytoma is excluded 1
• Do not perform surgery for bilateral hyperaldosteronism—medical management is the correct approach 1
• Do not delay treatment of suspected adrenal crisis for diagnostic testing—draw blood for cortisol/ACTH then immediately administer hydrocortisone and saline 1
• In patients <40 years with unilateral imaging findings and hyperaldosteronism, adrenal vein sampling may be omitted as bilateral hyperplasia is rare 1

Follow-Up Requirements

• For resected adrenal carcinoma: CT abdomen/chest every 3 months for 2 years, then gradually increase intervals, continuing for at least 10 years 1
• For adrenal insufficiency: annual review with assessment of weight, blood pressure, serum electrolytes, and screening for new autoimmune disorders 1
• For functioning adenomas post-surgery: biochemical testing at 14 days, then every 3-4 months for 2-3 years 1