It is hard to find adrenal carcinomas early and they are often quite large when diagnosed. Adrenal carcinomas are often found earlier in children than in adults because adrenal cancers in children more commonly secrete hormones. Children will show outward signs of excess hormone production early. For example they may develop very early signs of puberty due to the sex hormones that sometimes are produced by adrenal cancer. In adults, these tumors may be found early by accident, when a CT (computed tomography) scan is done for some other health concern.
The American Cancer Society has official recommendations for the early detection of several types of cancer. Because adrenal cancers occur so rarely, the Society does not recommend routine testing for this cancer in people without any symptoms.
Signs and Symptoms of Adrenal Cancers
In about half of people with adrenal cancer, symptoms are caused by the hormones made by the tumor. In the other half, symptoms occur because the tumor has grown so large that it presses on nearby organs. If you or your child has any of the signs or symptoms described in this section, discuss them with your doctor without delay. These symptoms may be caused by an adrenal tumor or by something else. Getting the proper medical tests is the only way to find out. The sooner you get a correct diagnosis, the sooner you can start treatment and the more effective your treatment will be.
Symptoms Caused by Androgen or Estrogen Production
In children, the symptoms are most often caused by the androgens (male-type hormones) that the tumor might secret. The most common symptoms are excessive growth of facial and body hair (such as in the pubic and underarm areas). Male hormones may also enlarge the penis is boys or the clitoris in girls.
If the tumor secretes estrogens (female-type hormones), girls can start puberty early. This can cause the breasts to develop and menstrual periods to start. Estrogen-producing tumors also may enlarge breasts in boys.
The symptoms from high levels of sex hormones are less noticeable in adults because they have already gone through puberty and have breasts and adult patterns of body hair. Women with estrogen-producing tumors and men with androgen-producing tumors usually do not have any symptoms from the hormones, and so may have no symptoms until the tumor is large enough to press on nearby organs.
Symptoms are easier to notice if the tumor is making the hormone usually found in the opposite sex. For example, men with tumors that make estrogen (female hormone) may notice breast enlargement with tenderness. They may also have sexual problems such as erectile dysfunction (impotence) and loss of sex drive. Women with tumors that make androgens (male hormones) may notice excessive facial and body hair growth, receding hairline, irregular menstrual periods, and deepening of their voice.
Symptoms Caused by Cortisol Production
Excessive levels of cortisol causes a problem known as Cushing syndrome. Some people have all of these symptoms, but many people with high cortisol levels have only 1 or 2 symptoms. These signs and symptoms include:
- Weight gain, usually greatest above the collar bone and around the abdomen
- Fat deposits behind the neck and shoulders
- Purple stretch marks on the abdomen
- Excessive hair growth on the face, chest, and back in women
- Menstrual irregularities
- Weakness and loss of muscle mass in the legs
- Easy bruising
- Depression and/or moodiness
- Weakened bones (osteoporosis), which can lead to fractures
- High blood sugar, often leading to diabetes
- High blood pressure
Cushing syndrome may be caused by an adrenal cancer or an adrenal adenoma that produces high levels of cortisol and/or related hormones. Benign pituitary gland tumors can produce high levels of another hormone called adrenocorticotropic hormone (ACTH). This is often called Cushing disease. The high levels of ACTH in turn cause normal adrenal gland tissue to produce more cortisol. This results in the same symptoms as Cushing syndrome. Very rarely ACTH can be produced by other tumors and cause the same symptoms.
Some people with immune system problems or some cancers, such as lymphomas, are treated with drugs chemically related to cortisol. Because there are so many causes of high cortisol levels that can lead to Cushing syndrome, doctors do a number of blood tests, urine tests, and imaging tests to find out whether the patient has an adrenal cortical tumor or some other cause of Cushing syndrome.
Symptoms Caused by Aldosterone Production
The main signs and symptoms caused by aldosterone-producing adrenal tumors are:
- High blood pressure
- Muscle cramps
- Low blood potassium levels
Adrenal adenomas often produce aldosterone, but adrenal cancers rarely do so.
Symptoms Caused by a Large Adrenal Cancer Pressing on Nearby Organs
As an adrenal cancer grows, it presses on nearby organs and tissues. This may cause pain near the tumor, a feeling of fullness in the abdomen, or trouble eating because of a feeling of filling up easily.
How is Adrenal Cancer Diagnosed?
Medical History and Physical Exam
The first step is for the doctor to take your complete medical history to check for any symptoms. Your doctor will want to know if anyone in your family has had adrenal cancer or any other type of cancer. Your doctor will also ask about your menstrual or sexual function and about any other symptoms that you may be having. A physical exam will give other information about signs of adrenal gland cancer and other health problems. Your doctor will thoroughly examine your abdomen for evidence of a tumor (or mass).
Your blood and urine will be tested to look for high levels of the hormones produced by some adrenal adenomas and carcinomas. If an adrenal tumor or cancer is suspected, imaging tests will be done to look for a tumor. These tests can also help see if it has spread.
If a mass is seen on an imaging test and it is likely to be an adrenal cancer, doctors will recommend surgery to remove the cancer. Generally, doctors do not recommend a biopsy (removing a sample of the tumor to look at under the microscope to see if it is cancer) before surgery to remove the tumor. That is because doing a biopsy can increase the risk that an adrenal cancer will spread outside of the adrenal gland.
This can show if the cancer has spread to the lungs. It may also be useful to determine if there are any serious lung or heart diseases.
Ultrasound tests use sound waves to take pictures of parts of the body. A device called a transducer produces the sound waves, which are reflected by tissues of nearby organs. The pattern of sound wave echoes is detected by the transducer and analyzed by a computer to create an image of these tissues and organs. This test can show if there is a tumor mass in the adrenal gland. It can also diagnose tumor masses in the liver if the cancer has spread there. In general, it is not used to look for adrenal tumors unless a CT scan isn’t able to be done.
Computed Tomography (CT)
CT scans show the adrenal glands fairly clearly and often can confirm the location of the cancer. It can also help show whether your cancer has spread into your liver or other organs nearby. CT scans can also show lymph nodes and distant organs where metastatic cancer might be present. The CT scan can help determine if surgery is a good treatment option.
The CT scan is an x-ray procedure that produces detailed cross-sectional images of your body. CT scans take longer than regular x-rays. Instead of taking one picture, like a conventional x-ray, a CT scanner takes many pictures as the camera rotates around you. A computer then combines these pictures into an image of a slice of your body. The machine will take pictures of many slices of the part of your body that is being studied.
A CT scanner has been described as a large donut, with a narrow table in the middle opening. You will need to lie still on the table while the scan is being done. CT scans take longer than regular x-rays, and you might feel a bit confined by the ring while the pictures are being taken. Before any pictures are taken, you may be asked to drink 1 to 2 pints of a liquid called oral contrast. This helps outline the stomach and intestine to make abnormal areas easier to spot. You may also receive an IV line through which a different kind of contrast dye (IV contrast) is injected. This helps better outline structures such as blood vessels in your body.
The injection can cause some flushing (redness and a feeling of warmth that may last hours to days). A few people are allergic to the dye and get hives. Rarely, more serious reactions like trouble breathing and low blood pressure can occur. Medicine can be given to prevent and treat allergic reactions. Be sure to tell the doctor if you have ever had a reaction to any contrast material used for x-rays.
CT scans can also be used to precisely guide a biopsy needle into a suspected metastasis. For this procedure, called a CT-guided needle biopsy, the patient remains on the CT scanning table, while a radiologist moves a biopsy needle toward the location of the mass. CT scans are repeated until the doctors are sure that the needle is within the mass. A fine needle biopsy sample (tiny fragment of tissue) or a core needle biopsy sample (a thin cylinder of tissue about ½ inch long and less than 1/8 inch in diameter) is removed and examined under a microscope.
Positron Emission Tomography (PET)
In this test, radioactive glucose (sugar) is injected into the patient’s vein. Because cancer cells use sugar much faster than normal tissues, radioactivity will tend to concentrate in the cancer. A scanner can spot the radioactive deposits. This test can be helpful in spotting small collections of cancer cells and may be used to find cancer that has spread. It also may help in deciding if an adrenal tumor is likely to be benign or malignant (cancer).
A special type of PET scan is currently used only in research settings. It uses a radioactive form of a substance called metomidate. This substance seems to concentrate in adrenal cortical tissue, particularly adenomas and carcinomas. PET scanning with metomidate may in the future be helpful in distinguishing tumors that start in the adrenal cortex from cancers that started in other organs and then spread to the adrenals. It may also be helpful in finding adrenal cancer that has spread outside the adrenals.
Magnetic Resonance Imaging (MRI)
MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of tissue and by certain diseases. A computer translates the pattern of radio waves given off by the tissues into a very detailed image of parts of the body. Not only does this produce cross sectional slices of the body like a CT scanner, it can also produce slices that are parallel with the length of your body. For some MRI scans, a contrast material called gadolinium is injected into a vein (IV). MRI may sometimes provide more information than CT scans because it can better distinguish adrenal cancers from benign tumors.
MRI scans are particularly helpful in examining the brain and spinal cord. In people with suspected adrenal tumors, an MRI of the brain may be done to examine the pituitary gland. Tumors of the pituitary gland, which lies underneath the front of the brain, can cause symptoms and signs similar to adrenal tumors.
MRI scans are a little more uncomfortable than CT scans. First, they take longer. You have to be placed inside a tube, which is confining and can upset people who become anxious in tight spaces (claustrophobia). If you have problems with tight spaces, tell your doctor before your MRI. Medicine may be given before the scan to help with anxiety. If that doesn’t work, the exam may be scheduled at an open MRI scanner. These machines are not so enclosing and so are easier for some patients, although the drawback is that the pictures may not be as good. The machine also makes a thumping noise that you might find disturbing. Some places will provide headphones with music to block this sound out.