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Why Difficult for Doctors to Diagnose Adrenal Cancer

Why Difficult for Doctors to Diagnose Adrenal Cancer

Cancer starts when cells mutate and grow out of control. The abnormal cells often develop to form a lump or mass called a tumor. They may spread to other parts of the body. This is called metastasis.

Adrenal cancer is rare cancer. It starts in the adrenal glands. You have two adrenal glands. One sits on top of each kidney. The two kidneys are deep in the upper part of your belly (abdomen). The adrenal glands make hormones that balance the salt in your body and help control blood pressure. They also produce hormones that control how your body gets energy from food and reacts to stress. The adrenal glands produce a small number of sex hormones, too.

Each adrenal gland has two main parts. The outer part of the adrenal gland is called the adrenal cortex. Most adrenal cancers start in this area. The inner part is called the adrenal medulla.

Difficulty in diagnosing adrenal cancer 

Most tumors in the adrenal glands are not cancer. These may be called benign tumors. It’s often hard to tell if an adrenal tumor is malignant or benign. If the tumor grows and spreads to lymph nodes or other body parts, it’s malignant cancer. Benign tumors don’t spread.

Following are the reasons doctors find it challenging to diagnose adrenal cancer. 

Lack of practical screening test

There is a lack of practical screening tests for diagnosing adrenal cancer. It is impossible to confirm adrenal cancer through mammography for breast cancer, or colonoscopy for colorectal cancer. Some adrenal cancers overproduce hormones, and then in those scenarios, with the help of tests for those hormones meaning cortisol, testosterone, estrogen, androgens, cancer can be diagnosed. 

However, not all adrenal cancers produce these hormones. X-ray tests such as CT and MRI scans have their role in diagnosing adrenal cancer but are not effective enough to function as screening tests. 

Indeed, any patient who has undergone a CT scan of their abdomen should make sure that their doctor and radiologist look at the adrenal glands to diagnose any masses of the adrenal glands.

Not common type of cancer: 

This is a rare type of cancer. Most doctors in primary care, internal medicine or surgery have never met an adrenal cancer patient. Even doctors specializing in endocrinology or endocrine surgery can have gone through their entire training without meeting an adrenal cancer patient.

This means that very few doctors have significant expertise in diagnosing adrenal cancer.

The initial evaluation of a patient to diagnose adrenal cancer should include blood tests to measure adrenal hormones in the circulation (blood and urine hormone tests). Since most of these cancers produce too much hormone (cortisol, testosterone, estrogen, other androgens, DHEAS, aldosterone, etc.), this is a prominent place to start. However, most non-cancerous tumors of the adrenal glands (benign adenomas and hyperplasia) may also secrete more hormones. Therefore, demonstrating overproduction of adrenal hormones helps diagnose an adrenal tumor, yet it does not always help distinguish between benign and malignant (cancerous) tumors. However, extremely high levels are more commonly produced by malignant tumors (adrenal cancer).

Adrenal cancer overproducing hormones can cause many different symptoms. 

Many patients will seek medical attention with some bodily change which typically comes on quite slowly (usually over 1 to 3 years). Excess female hormones are produced in a female, it can be hard to diagnose, except at extremes of age, such as early puberty in a child or the return of vaginal bleeding in a post-menopausal woman. The same is true for excess testosterone in a male. The opposite, however, will often make the diagnosis obvious, such as when a woman develops male characteristics (deeper voice, excess body hair) or a man begins to develop enlarged breasts (gynecomastia). 

Some of these hormone overproduction diseases have specific names:

  • Hypercortisolism. It causes excess production of cortisol.
  •  Adrenogenital syndrome. It produces excess sex steroids.
  • Virilization. Because of excess testosterone production, acquisition of male traits in a female.
  • Feminization. Because of excess estrogen production, acquisition of female traits in a male. 
  • Precocious puberty. Because of excessive production of sex steroids, puberty occurs early. 
  • Hyperaldosteronism. Excess aldosterone leading to hypertension and low potassium.

Adrenal cancers are tucked in the very back of the abdomen and grow very large before they cause pain and discomfort.

The adrenal glands are located on top of the kidneys very far back in the abdomen (technically in the retroperitoneum). That means that they can grow quite large before they cause any symptoms. For patients with no hormone production, it is not unusual for adrenal cancer to grow to the size of a cantaloupe before it causes pain in the abdomen and the flank. Almost all patients with adrenal cancer seek medical attention because of pain unless they have apparent hormone overproduction.

Small adrenal masses on scans (CT and MRI) may be overlooked as a way to diagnose early adrenal cancer.

An adrenal incidentaloma (sometimes termed “incidentally found” adrenal mass or adrenal nodule) is an adrenal growth that is diagnosed when a radiological scan (X-ray, CT scan, or MRI) is performed for indications other than for adrenal disease. Most commonly, adrenal incidentalomas are found on CT abdomen scans for some other reason.

Adrenal incidentalomas are pretty standard and become more common as we age. In autopsy studies of people who died of natural causes, about 6 % of all people have an adrenal mass or adrenal tumor that they were completely unaware of. Therefore, small adrenal tumors are common, occurring in about 4-5 percent of us in our lifetime, so you can imagine that many people having a CT scan will have an adrenal tumor found that they did not know.

The tricky part for doctors is to diagnose the small adrenal cancers among all these tumors. Unfortunately, many doctors believe that all small adrenal tumors are not cancerous, so many of our adrenal cancer patients have been diagnosed with an adrenal mass based on a previous scan, but no doctor took it seriously. They did not have a follow-up scan, and they did not have their adrenal hormone levels checked. This is very bad!

Suppose you ever had an adrenal mass diagnosed on a CT scan and did not have it removed. In that case, you must have a follow-up scan to ensure it has not grown or is overproducing any of the adrenal hormones (cortisol, testosterone, estrogen, other androgens, DHEAS, aldosterone, etc.), which are problematic for cancer.

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