Bilateral adrenal masses: a single-centre experience

Abstract

Background: Bilateral adrenal masses may have aetiologies like hyperplasia and infiltrative lesions, besides tumours. Hyperplastic and infiltrative lesions may have coexisting hypocortisolism. Bilateral tumours are likely to have hereditary/syndromic associations. The data on clinical profile of bilateral adrenal masses are limited.

Aims: To analyse clinical, biochemical and radiological features, and management outcomes in patients with bilateral adrenal masses.

Methods: Retrospective analysis of 70 patients with bilateral adrenal masses presenting to a single tertiary care endocrine centre from western India (2002-2015).

Results: The most common aetiology was pheochromocytoma (40%), followed by tuberculosis (27.1%), primary adrenal lymphoma (PAL) (10%), metastases (5.7%), non-functioning adenomas (4.3%), primary bilateral macronodular adrenal hyperplasia (4.3%), and others (8.6%). Age at presentation was less in patients with pheochromocytoma (33 years) and tuberculosis (41 years) compared with PAL (48 years) and metastases (61 years) (P<0.001). The presenting symptoms for pheochromocytoma were hyperadrenergic spells (54%) and abdominal pain (29%), whereas tuberculosis presented with adrenal insufficiency (AI) (95%). The presenting symptoms for PAL were AI (57%) and abdominal pain (43%), whereas all cases of metastasis had abdominal pain. Mean size of adrenal masses was the largest in lymphoma (5.5cm) followed by pheochromocytoma (4.8cm), metastasis (4cm) and tuberculosis (2.1cm) (P<0.001). Biochemically, most patients with pheochromocytoma (92.8%) had catecholamine excess. Hypocortisolism was common in tuberculosis (100%) and PAL (71.4%) and absent with metastases (P<0.001).

Conclusion: In evaluation of bilateral adrenal masses, age at presentation, presenting symptoms, lesion size, and biochemical features are helpful in delineating varied underlying aetiologies.

Keywords: adrenal; endocrine cancers.

Figure 1

(A) Bilateral pheochromocytomas (right 3.6 cm, left 3.2 cm) having intense contrast enhancement. (B) Bilateral adrenal tuberculosis (right 1.6 cm, left 1 cm) with calcification in left adrenal and poor contrast uptake. (C) Bilateral primary adrenal lymphoma (right 4.4 cm, left 7.8 cm) with area of necrosis and mild contrast enhancement. (D) Bilateral adrenal metastasis (right 5 cm, left 5 cm) with areas of necrosis and mild contrast enhancement. (E) Bilateral adrenal adenomas (right 2.5 cm, 1.8 cm) with baseline HU <10. (F) Primary bilateral macronodular adrenal hyperplasia (right 4cm, left 3cm) maintaining adeniform shape.

Figure 2

(A) Age-wise presentation of pheochromocytoma, tuberculosis, lymphoma and metastasis. (B) Comparison of duration of symptoms in pheochromocytoma, tuberculosis, lymphoma and metastasis.

Figure 3

Approach to bilateral adrenal masses. ACTH: adrenocorticotropic hormone, CT: computerized tomography, ODST: oral dexamethasone suppression test, PBMAH: primary bilateral macronodular adrenocorticotropic hyperplasia.