An adrenal mass is a lump found in one of the adrenal glands, which sit just above the kidneys. Most adrenal masses are benign and are found accidentally during USG, CT or MRI done for another reason. But every adrenal mass should be reviewed properly to answer two questions: Is it producing excess hormones? and Does it look suspicious for cancer? Many patients need only observation, but some need hormone tests, adrenal-protocol imaging, specialist follow-up or adrenal surgery. Current adrenal incidentaloma guidelines recommend structured imaging and hormone evaluation rather than ignoring the finding.

Short answer: Should I worry about an adrenal mass?

Most adrenal masses are not cancer. Many are harmless adrenal adenomas. The important step is to confirm that the mass is not producing excess hormones and does not have suspicious imaging features.

A patient should not panic after reading “adrenal mass” on a scan report. But it should not be casually ignored either, especially if it is large, irregular, growing, hormonally active or found in someone with a previous cancer history.

What are the adrenal glands?

The adrenal glands are small hormone-producing glands located above both kidneys. Each person usually has two adrenal glands: one on the right and one on the left.

They help control:

• Blood pressure.
• Salt and potassium balance.
• Stress response.
• Sugar metabolism.
• Some sex-hormone pathways.

An adrenal mass may occur in the right adrenal gland, left adrenal gland or both. The word mass means a lump or lesion. It does not automatically mean cancer.

What is an adrenal incidentaloma?

An adrenal incidentaloma is an adrenal mass found accidentally during imaging done for another reason, such as abdominal pain, kidney stone evaluation, back pain, trauma, fever work-up or cancer follow-up. The European Society of Endocrinology describes adrenal incidentalomas as adrenal masses detected on imaging performed for reasons other than suspected adrenal disease.

Most adrenal incidentalomas are benign, but some need further evaluation because they may produce hormones, look suspicious on imaging or rarely represent adrenal cancer or metastasis.

Why a urologist may be involved

Adrenal masses often need a team approach. Depending on the case, evaluation may involve a urologist, endocrinologist, radiologist, endocrine surgeon, oncologist or physician.

A urologist commonly becomes involved when:

• The mass is found during kidney stone, kidney pain, hematuria or abdominal CT evaluation.
• Adrenalectomy surgery may be needed.
• There is a kidney cancer or urinary cancer history.
• The adrenal mass may be related to metastasis.
• The patient needs counselling about laparoscopic, robotic or open adrenal surgery.

What can cause an adrenal mass?

Symptoms of an adrenal mass

Many adrenal masses cause no symptoms. They are found on imaging. Symptoms may occur if the mass produces hormones or becomes large.

Symptoms suggesting pheochromocytoma

A pheochromocytoma can release adrenaline-like hormones. Symptoms may come in attacks. Possible symptoms include:

• Sudden high BP episodes.
• Severe headache.
• Sweating.
• Palpitations or fast heartbeat.
• Tremors.
• Anxiety-like spells.
• Chest discomfort.
• Weakness after an episode.

Plasma free metanephrines or urinary fractionated metanephrines are standard biochemical tests when pheochromocytoma is suspected. The 2023 European adrenal-incidentaloma guideline allows metanephrine testing to be omitted when an adrenal lesion is clearly a benign adenoma on unenhanced CT (homogeneous and 10 HU or less); indeterminate lesions should still be assessed for pheochromocytoma, especially before biopsy or surgery.

Symptoms suggesting excess cortisol

Excess cortisol may cause:

• Weight gain, especially around the abdomen or face.
• Diabetes or worsening sugar control.
• High blood pressure.
• Muscle weakness.
• Easy bruising.
• Thin skin.
• Recurrent infections.
• Mood changes.
• Purple stretch marks in some patients.

For adrenal incidentalomas, guidelines recommend a 1 mg overnight dexamethasone suppression test to check for autonomous cortisol secretion in most patients, except selected frail patients where testing may not be useful.

Symptoms suggesting excess aldosterone

Excess aldosterone may cause:

• High blood pressure.
• Difficult-to-control BP despite medicines.
• Low potassium.
• Muscle cramps.
• Muscle weakness.
• Excess thirst or urination in some patients.

Primary aldosteronism is an adrenal-related cause of high blood pressure. In patients with adrenal mass plus hypertension or unexplained low potassium, doctors may advise an aldosterone-renin ratio test.

Symptoms suggesting a large or suspicious mass

A large or suspicious adrenal mass may cause:

• Persistent upper abdominal pain.
• Flank or back pain.
• Abdominal fullness.
• Unexplained weight loss.
• Loss of appetite.
• Fever or weakness.
• New hormonal changes.

Adrenocortical carcinoma is rare, but it is a cancer that forms in the adrenal glands and needs specialist diagnosis and treatment.

What does my adrenal report mean?

Patients often see confusing words in CT or MRI reports. This table can help you understand the language.

Which CT or MRI findings are reassuring?

A homogeneous adrenal mass with HU <=10 on non-contrast CT is strongly suggestive of a benign adrenal lesion. In many such cases, further adrenal imaging may not be needed.

Reassuring features include:

• Small size.
• Smooth margins.
• Homogeneous appearance.
• Non-contrast HU <=10.
• Stable appearance compared with old scans.
• Clear features of myelolipoma or cyst.
• Normal hormone tests.

Which findings need closer evaluation?

An adrenal mass needs closer evaluation if the report mentions:

• Size 4 cm or more.
• HU more than 20.
• Heterogeneous appearance.
• Irregular margins.
• Necrosis or bleeding inside the mass.
• Local invasion.
• Rapid growth.
• Bilateral adrenal masses.
• Past history of cancer.
• Symptoms of hormone excess.

The 2023 European guideline recommends that indeterminate adrenal masses be characterised carefully and discussed in an expert multidisciplinary setting when imaging or hormone findings are concerning. A homogeneous mass with unenhanced CT attenuation of 10 HU or less has benign imaging features and generally needs no further imaging, irrespective of size.

Tests commonly advised for adrenal mass

Clinical review

Your doctor will ask about:

• High BP.
• Diabetes.
• Weight gain.
• Weakness.
• Headache attacks.
• Sweating.
• Palpitations.
• Low potassium.
• Past cancer history.
• Steroid medicine use.

Basic blood tests

Common tests include:

• Blood pressure record.
• Serum potassium.
• Serum creatinine.
• Fasting sugar or HbA1c.
• Sodium and other electrolytes if needed.

Hormone tests

Adrenal CT or MRI

A dedicated adrenal CT or MRI may be advised if the first scan is incomplete or unclear. CT, MRI, FDG-PET/CT and biopsy are used selectively depending on the patient’s clinical situation, size, imaging features and cancer history.

Does every adrenal mass need biopsy?

No. Adrenal biopsy is rarely the first step.

Biopsy is usually avoided unless:

• The patient has a known cancer elsewhere.
• The result will change treatment.
• Pheochromocytoma has been ruled out.
• Adrenocortical carcinoma is not the main suspicion.
• The procedure is being done by an experienced team.

Routine adrenal biopsy is not recommended in standard adrenal mass evaluation. It can be dangerous if pheochromocytoma has not been excluded, and it is not usually helpful when adrenal cancer is suspected.

Treatment options for adrenal mass

Treatment depends on whether the mass is clearly benign, hormonally active, suspicious, growing or related to another cancer.

Observation

Observation may be enough if:

• The mass looks clearly benign.
• Hormone tests are normal.
• There are no worrying symptoms.
• There is no cancer history.
• The mass is stable or has reassuring CT/MRI features.

In clearly benign adrenal lesions, repeated imaging and repeated hormone testing may not be needed unless new symptoms appear or BP/diabetes worsens.

Medicines and hormone control

Medicines may be needed if hormone excess is present. For example:

• BP control before pheochromocytoma surgery.
• Potassium and BP control in aldosterone excess.
• Diabetes, BP, bone and cardiovascular risk management in cortisol excess.
• Cancer-specific medicines in selected adrenal cancer cases.

Do not self-medicate with BP tablets, steroids, hormonal supplements or “adrenal support” products without evaluation.

Adrenalectomy surgery

Adrenalectomy means surgical removal of the adrenal gland.

Surgery may be advised if:

• The mass is producing significant hormones.
• Pheochromocytoma is confirmed or strongly suspected.
• The mass is suspicious for cancer.
• The mass is growing.
• The mass is large and indeterminate.
• There are pressure symptoms.
• It may be an isolated metastasis in selected cancer patients.

Surgery can be laparoscopic, robotic or open. Minimally invasive surgery may be suitable for selected benign or hormone-producing adrenal tumors. Open surgery is preferred when there is strong suspicion of adrenal cancer or local invasion.

What happens after the first consultation?

After reviewing your scan, symptoms and medical history, your doctor may advise one of four paths:

Most patients do not need immediate surgery. The first goal is to classify the adrenal mass correctly.

Recovery after adrenal surgery

Recovery depends on the type of surgery, size of the mass, hormone status and overall health. In general:

• Laparoscopic or robotic surgery usually has smaller cuts and faster recovery.
• Open surgery may be needed for large or cancer-suspicious masses.
• BP and sugar may improve in some hormone-producing tumors, but medicines should be adjusted only under medical supervision.
• Some patients need temporary steroid replacement after surgery, especially if cortisol excess was present.
• Follow-up hormone testing may be needed.

What to bring for consultation

• CT/MRI/USG report.
• CT/MRI films or CD, not only the printed report.
• Previous scans, if available.
• BP records.
• Current BP, diabetes and steroid medicines.
• Serum potassium and creatinine reports.
• HbA1c or diabetes reports.
• Any hormone tests already done.
• Cancer history, biopsy reports or treatment summaries.
• Discharge summaries from previous admissions.
• Symptoms diary: headache, sweating, palpitations, BP spikes, weakness, weight changes.

Questions to ask your doctor

• Does this adrenal mass look benign or indeterminate?
• What is the size?
• What is the HU value on non-contrast CT?
• Is it homogeneous or heterogeneous?
• Do I need hormone testing?
• Do I need adrenal-protocol CT or MRI?
• Is biopsy needed or should it be avoided?
• Do I need surgery?
• If surgery is needed, can it be laparoscopic or robotic?
• How often should I follow up?

FAQs

Related reading

• Blood in Urine: Causes and Tests
• CT KUB and Abdominal CT: What Patients Should Know
• Renal Cyst on Ultrasound: Simple vs Complex Cyst
• Adult Circumcision: Procedure, Recovery and Risks
• Urologist in Latur

References

• Endocrine Society guideline on pheochromocytoma and paraganglioma biochemical testing https://academic.oup.com/jcem/article/99/6/1915/2537399
• Endocrine Society primary aldosteronism guideline https://www.endocrine.org/clinical-practice-guidelines/primary-aldosteronism-2
• American College of Radiology Appropriateness Criteria: Adrenal Mass Evaluation )00710-9/fulltext https://www.jacr.org/article/S1546-1440(21
• National Cancer Institute. Adrenocortical Carcinoma Treatment https://www.cancer.gov/types/adrenocortical