Can an adrenal tumor be treated without surgery?

Can Adrenal Tumors Be Treated Without Surgery?

Surgery is of utmost importance in the treatment of adrenal tumors, and complete surgical resection (R0 resection) provides the only means to achieve long-term survival for adrenocortical carcinoma (ACC). 1 Non-surgical management is reserved only for highly specific scenarios where surgery is not feasible or appropriate.

When Non-Surgical Management May Be Considered

For Benign, Non-Functioning Tumors

• Observation alone is appropriate for homogeneous lesions ≤10 Hounsfield units on unenhanced CT, as these are definitively benign and require no treatment or additional imaging regardless of size 2
• Small benign-appearing adenomas (<4 cm) that remain unchanged on repeat imaging at 6-12 months can be followed without surgery 1
• Myelolipomas identified by characteristic radiographic features without symptoms can be observed with repeat imaging 1

For Advanced Malignant Disease (Stage IV ACC)

Non-surgical systemic therapy becomes the primary treatment when:

• Metastatic disease is present with high tumor burden or rapid progression 1, 3
• Systemic chemotherapy options include mitotane monotherapy or combinations of cisplatin, etoposide, doxorubicin, and mitotane 1
• The combination of mitotane with cisplatin, etoposide, and doxorubicin achieved a 49% overall response rate in unresectable ACC 1

For Indolent Malignant Pheochromocytoma/Paraganglioma

• Watch-and-wait approach may be considered for low tumor burden disease that behaves very indolently and remains stable for months to years 1
• Blood pressure should be controlled with alpha blockers during observation 1
• Radionuclide therapy (MIBG or DOTATOC) is an option for progressive or symptomatic disease 1

Medical Management of Hormone Excess

When surgery is contraindicated or delayed, hormone-related symptoms can be managed medically:

• For Cushing syndrome: Ketoconazole (400-1200 mg/day) or mitotane as adrenostatic agents 1
• For hyperaldosteronism with bilateral disease: Spironolactone or eplerenone for hypertension and hypokalemia 1
• For pheochromocytoma: Phenoxybenzamine or other alpha-blockers for blood pressure control 4

Critical Limitations of Non-Surgical Approaches

Why Surgery Remains Essential

• R0 (margin-free) resection is the only curative treatment and the major predictor of prognosis for ACC 1, 3
• Even for recurrent disease, repeat surgery improves survival if R0 resection is achievable and time to first recurrence was >12 months 1
• Adrenal surgery should only be performed in specialized centers performing >10 adrenalectomies for adrenal cancer per year 1, 5

When Surgery Cannot Be Avoided

Surgery is mandatory for:

• All suspected malignant tumors (>4 cm with inhomogeneous appearance or HU >20) 2
• All functioning tumors causing hormone excess (pheochromocytoma, aldosteronoma, cortisol-producing adenomas) 5, 2
• Localized ACC (stages I-III) when complete resection is achievable 1, 3
• Tumors 4-6 cm with aggressive features or any tumor >6 cm 1

Palliative Cytoreductive Surgery

Even in advanced disease, debulking surgery (R2 resection) may improve quality of life and survival by:

• Reducing tumor burden and controlling hormonal hypersecretion in malignant pheochromocytoma 1
• Managing severe symptomatic hormone excess in ACC when medical therapy fails and life expectancy is >6 months 1
• Facilitating better response to subsequent systemic therapy 1

Common Pitfalls to Avoid

• Never perform laparoscopic surgery on tumors >8 cm or with features suspicious for malignancy, as this increases risk of local recurrence and peritoneal spread 1, 3
• Do not biopsy suspected ACC as this risks tumor spillage; biopsy is only appropriate when metastatic disease from another primary cancer is suspected 3
• Failure to provide adequate corticosteroid replacement after resection of cortisol-producing tumors can lead to life-threatening adrenal crisis 5
• Medical management alone for functioning tumors leaves patients at risk of hormone-related morbidity and mortality 1