Laboratory Studies

Serum laboratory studies include the following:

Electrolyte levels
Cortisol levels
Androgen levels
Free metanephrine levels (most sensitive test for pheochromocytoma)

Urine studies that may be included in the evaluation are as follows:

24-hour catecholamine levels
24-hour metanephrine levels (most specific test for pheochromocytoma)
24-hour free cortisol levels
17-ketosteroids and 17-hydroxycorticosteroids levels

If a pheochromocytoma is suspected, a clonidine suppression test or glucagon stimulation test can be performed to confirm the diagnosis.

Imaging studies

Computed tomography (CT) has become the criterion standard. Other imaging studies often are used in conjunction with the CT scan in the diagnosis of adrenal masses.

Magnetic resonance imaging (MRI) frequently is useful in delineating lesions. In the case of adrenocortical carcinoma, regardless of size or function, if T2-weighted images from an MRI reveal a high-intensity signal, this finding is strongly suggestive of a malignancy, and exploration is warranted.

Nuclear scans such as a metaiodobenzylguanidine (MIBG) scan or an iodine-131-beta-iodomethyl-norcholesterol (NP-59) scan can also help delineate between malignant and benign lesions. An MIBG scan may be helpful with pheochromocytomas because MIBG is taken up in the norepinephrine pathway and suggests function. NP-59 is taken up by the adrenal cortex and by adenomas. Space-occupying lesions, such as adrenocortical carcinoma, do not take up the tracer.

Other tests

Other tests that may be used in the workup include the following:

Blood pressure
Serum potassium levels (for aldosteronoma)

Treatment & Management

Mayo CH. Paroxysmal hypertension with tumor of the retroperitoneal nerve. JAMA. 1927. 89:1047.
Crout JR, Pisano JJ, Sjoerdsma A. Urinary excretion of catecholamines and their metabolites in pheochromocytoma. Am Heart J. 1961 Mar. 61:375-81. [QxMD MEDLINE Link].
Nitschke R, Smith EI, Shochat S, et al. Localized neuroblastoma treated by surgery: a Pediatric Oncology Group Study. J Clin Oncol. 1988 Aug. 6(8):1271-9. [QxMD MEDLINE Link].
[Guideline] Grumbach MM, Biller BM, Braunstein GD, Campbell KK, Carney JA, Godley PA, et al. Management of the clinically inapparent adrenal mass ("incidentaloma"). Ann Intern Med. 2003 Mar 4. 138(5):424-9. [QxMD MEDLINE Link].
Tritos NA, Cushing GW, Heatley G, Libertino JA. Clinical features and prognostic factors associated with adrenocortical carcinoma: Lahey Clinic Medical Center experience. Am Surg. 2000 Jan. 66(1):73-9. [QxMD MEDLINE Link].
Wooten MD, King DK. Adrenal cortical carcinoma. Epidemiology and treatment with mitotane and a review of the literature. Cancer. 1993 Dec 1. 72(11):3145-55. [QxMD MEDLINE Link].
Hirano D, Hasegawa R, Igarashi T, Satoh K, Mochida J, Takahashi S, et al. Laparoscopic adrenalectomy for adrenal tumors: A 21-year single-institution experience. Asian J Surg. 2014 Nov 3. [QxMD MEDLINE Link].
Agrusa A, Romano G, Navarra G, et al. Innovation in endocrine surgery: robotic versus laparoscopic adrenalectomy. Meta-analysis and systematic literature review. Oncotarget. 2017 Nov 24. 8 (60):102392-400. [QxMD MEDLINE Link]. [Full Text].
Piccoli M, Pecchini F, Serra F, et al. Robotic versus laparoscopic adrenalectomy: pluriannual experience in a high-volume center evaluating indications and Results. J Laparoendosc Adv Surg Tech A. 2021 Apr. 31 (4):375-81. [QxMD MEDLINE Link]. [Full Text].
Walz MK, Peitgen K, Diesing D, et al. Partial versus total adrenalectomy by the posterior retroperitoneoscopic approach: early and long-term results of 325 consecutive procedures in primary adrenal neoplasias. World J Surg. 2004 Dec. 28(12):1323-9. [QxMD MEDLINE Link].
Janetschek G, Lhotta K, Gasser R, et al. Adrenal-sparing laparoscopic surgery for aldosterone-producing adenoma. J Endourol. 1997 Apr. 11(2):145-8. [QxMD MEDLINE Link].
Castinetti F, Qi XP, Walz MK, et al. Outcomes of adrenal-sparing surgery or total adrenalectomy in phaeochromocytoma associated with multiple endocrine neoplasia type 2: an international retrospective population-based study. Lancet Oncol. 2014 May. 15 (6):648-55. [QxMD MEDLINE Link].
McCall B. Adrenal-Sparing Surgery Better for Pheochromocytoma. Medscape Medical News. Available at http://www.medscape.com/viewarticle/845358#vp_1. May 26, 2015; Accessed: August 12, 2016.
Munver R, Del Pizzo JJ, Sosa RE. Adrenal-preserving minimally invasive surgery: the role of laparoscopic partial adrenalectomy, cryosurgery, and radiofrequency ablation of the adrenal gland. Curr Urol Rep. 2003 Feb. 4(1):87-92. [QxMD MEDLINE Link].
Schulsinger DA, Sosa RE, Perlmutter AP, Vaughan ED Jr. Acute and chronic interstitial cryotherapy of the adrenal as a treatment modality. World J Urol. 1999 Feb. 17(1):59-64. [QxMD MEDLINE Link].
Nakajo M, Hokotate H, Tsuchimochi S, et al. Non-surgical therapy of primary aldosteronism: transcatheter arterial infusion of ethanol into an aldosteronoma. Biomed Pharmacother. 2000 Jun. 54 Suppl 1:119s-132s. [QxMD MEDLINE Link].
Acosta E, Pantoja JP, Gamino R, Rull JA, Herrera MF. Laparoscopic versus open adrenalectomy in Cushing's syndrome and disease. Surgery. 1999 Dec. 126(6):1111-6. [QxMD MEDLINE Link].
Albala DM. Laparoscopic adrenalectomy. Marshall FF, ed. Textbook of Operative Urology. Philadelphia, Pa: WB Saunders Co; 1996. 193.
Bloom LS, Libertino JA. Surgical management of Cushing's syndrome. Urol Clin North Am. 1989 Aug. 16(3):547-65. [QxMD MEDLINE Link].
Blumenfeld JD, Sealey JE, Schlussel Y, et al. Diagnosis and treatment of primary hyperaldosteronism. Ann Intern Med. 1994 Dec 1. 121(11):877-85. [QxMD MEDLINE Link].
Brennan MF. Adrenocortical carcinoma. CA Cancer J Clin. 1987 Nov-Dec. 37(6):348-65. [QxMD MEDLINE Link].
Bukowski RM, Klein EA. Management of adrenal neoplasms. Vogelzang NJ, Scardino PT, Shipley WU, et al, eds. Comprehensive Textbook of Genitourinary Oncology. Baltimore, Md: Williams & Wilkins; 1996. 125.
Caplan RH, Strutt PJ, Wickus GG. Subclinical hormone secretion by incidentally discovered adrenal masses. Arch Surg. 1994 Mar. 129(3):291-6. [QxMD MEDLINE Link].
Cassady JR, Hutter JJ, Whitesell LJ. Neuroblastoma: Natural history and current therapy and approaches. Vogelzang NJ, Scardino PT, Shipley WU, et al, eds. Comprehensive Textbook of Genitourinary Oncology. Baltimore, Md: Williams & Wilkins; 1996. 98.
Cañete A, Jovani C, Lopez A, Costa E, Segarra V, Fernández JM, et al. Surgical treatment for neuroblastoma: complications during 15 years' experience. J Pediatr Surg. 1998 Oct. 33(10):1526-30. [QxMD MEDLINE Link].
Cerfolio RJ, Vaughan ED, Brennan TG, Hirvela ER. Accuracy of computed tomography in predicting adrenal tumor size. Surg Gynecol Obstet. 1993 Apr. 176(4):307-9. [QxMD MEDLINE Link].
Chan JE, Meneghetti AT, Meloche RM, Panton ON. Prospective comparison of early and late experience with laparoscopic adrenalectomy. Am J Surg. 2006 May. 191(5):682-6. [QxMD MEDLINE Link].
Conn JW. Primary aldosteronism. J Lab Clin Med. 1955 Apr. 45(4):661-4. [QxMD MEDLINE Link].
Conn JW, Cohen EL, Rovner DR. Landmark article Oct 19, 1964: Suppression of plasma renin activity in primary aldosteronism. Distinguishing primary from secondary aldosteronism in hypertensive disease. By Jerome W. Conn, Edwin L. Cohen and David R. Rovner. JAMA. 1985 Jan 25. 253(4):558-66. [QxMD MEDLINE Link].
Fassnacht M, Kenn W, Allolio B. Adrenal tumors: how to establish malignancy?. J Endocrinol Invest. 2004 Apr. 27(4):387-99. [QxMD MEDLINE Link].
Ganguly A. Primary aldosteronism. N Engl J Med. 1998 Dec 17. 339(25):1828-34. [QxMD MEDLINE Link].
Gockel I, Heintz A, Roth W, Junginger T. Adrenalectomy for bilateral and recurrent pheochromocytoma: increased intraoperative risk?. Am Surg. 2006 Mar. 72(3):232-7. [QxMD MEDLINE Link].
Godellas CV, Prinz RA. Surgical approach to adrenal neoplasms: laparoscopic versus open adrenalectomy. Surg Oncol Clin N Am. 1998 Oct. 7(4):807-17. [QxMD MEDLINE Link].
Hanssen WE, Kuhry E, Casseres YA, de Herder WW, Steyerberg EW, Bonjer HJ. Safety and efficacy of endoscopic retroperitoneal adrenalectomy. Br J Surg. 2006 Jun. 93(6):715-9. [QxMD MEDLINE Link].
Hough AJ, Hollifield JW, Page DL, Hartmann WH. Prognostic factors in adrenal cortical tumors. A mathematical analysis of clinical and morphologic data. Am J Clin Pathol. 1979 Sep. 72(3):390-9. [QxMD MEDLINE Link].
Imai T, Kikumori T, Ohiwa M, et al. A case-controlled study of laparoscopic compared with open lateral adrenalectomy. Am J Surg. 1999 Jul. 178(1):50-3; discussion 54. [QxMD MEDLINE Link].
Imperato-McGinley J, Gautier T, Ehlers K, et al. Reversibility of catecholamine-induced dilated cardiomyopathy in a child with a pheochromocytoma. N Engl J Med. 1987 Mar 26. 316(13):793-7. [QxMD MEDLINE Link].
Jossart GH, Burpee SE, Gagner M. Surgery of the adrenal glands. Endocrinol Metab Clin North Am. 2000 Mar. 29(1):57-68, viii. [QxMD MEDLINE Link].
Jovenich JJ. Anesthesia in adrenal surgery. Urol Clin North Am. 1989 Aug. 16(3):583-7. [QxMD MEDLINE Link].
Lumachi F, Ermani M, Basso SM, Armanini D, Iacobone M, Favia G. Long-term results of adrenalectomy in patients with aldosterone-producing adenomas: multivariate analysis of factors affecting unresolved hypertension and review of the literature. Am Surg. 2005 Oct. 71(10):864-9. [QxMD MEDLINE Link].
Luton JP, Cerdas S, Billaud L, et al. Clinical features of adrenocortical carcinoma, prognostic factors, and the effect of mitotane therapy. N Engl J Med. 1990 Apr 26. 322(17):1195-201. [QxMD MEDLINE Link].
Malone MJ, Libertino JA, Tsapatsaris NP, Woods BO. Preoperative and surgical management of pheochromocytoma. Urol Clin North Am. 1989 Aug. 16(3):567-82. [QxMD MEDLINE Link].
Manger WM, Gifford RW. Chap 102. Pheochromocytoma. Hypertension Pathophysiology Diagnosis and Management. 1990.
Nakada T, Kubota Y, Sasagawa I, et al. Therapeutic outcome of primary aldosteronism: adrenalectomy versus enucleation of aldosterone-producing adenoma. J Urol. 1995 Jun. 153(6):1775-80. [QxMD MEDLINE Link].
Neri LM, Nance FC. Management of adrenal cysts. Am Surg. 1999 Feb. 65(2):151-63. [QxMD MEDLINE Link].
Newell-Price J, Grossman A. Diagnosis and management of Cushing's syndrome. Lancet. 1999 Jun 19. 353(9170):2087-8. [QxMD MEDLINE Link].
Novick AC, Straffon RA, Kaylor W, Bravo EL. Posterior transthoracic approach for adrenal surgery. J Urol. 1989 Feb. 141(2):254-6. [QxMD MEDLINE Link].
Orth DN. Cushing's syndrome. N Engl J Med. 1995 Mar 23. 332(12):791-803. [QxMD MEDLINE Link].
Perry RR, Keiser HR, Norton JA, et al. Surgical management of pheochromocytoma with the use of metyrosine. Ann Surg. 1990 Nov. 212(5):621-8. [QxMD MEDLINE Link].
Schulick RD, Brennan MF. Long-term survival after complete resection and repeat resection in patients with adrenocortical carcinoma. Ann Surg Oncol. 1999 Dec. 6(8):719-26. [QxMD MEDLINE Link].
Smith CD, Weber CJ, Amerson JR. Laparoscopic adrenalectomy: new gold standard. World J Surg. 1999 Apr. 23(4):389-96. [QxMD MEDLINE Link].
Steinsapir J, Carr AA, Prisant LM, Bransome ED Jr. Metyrosine and pheochromocytoma. Arch Intern Med. 1997 Apr 28. 157(8):901-6. [QxMD MEDLINE Link].
Tada K, Okuda Y, Yamashita K. Three cases of malignant pheochromocytoma treated with cyclophosphamide, vincristine, and dacarbazine combination chemotherapy and alpha-methyl-p-tyrosine to control hypercatecholaminemia. Horm Res. 1998. 49(6):295-7. [QxMD MEDLINE Link].
Ulchaker JC, Goldfarb DA, Bravo EL, Novick AC. Successful outcomes in pheochromocytoma surgery in the modern era. J Urol. 1999 Mar. 161(3):764-7. [QxMD MEDLINE Link].
van Heerden JA, Sheps SG, Hamberger B, et al. Pheochromocytoma: current status and changing trends. Surgery. 1982 Apr. 91(4):367-73. [QxMD MEDLINE Link].
Vaughan ED Jr, Phillips H. Modified posterior approach for right adrenalectomy. Surg Gynecol Obstet. 1987 Nov. 165(5):453-5. [QxMD MEDLINE Link].
Walther MM, Keiser HR, Linehan WM. Pheochromocytoma: evaluation, diagnosis, and treatment. World J Urol. 1999 Feb. 17(1):35-9. [QxMD MEDLINE Link].

Media Gallery

Magnetic resonance imaging (MRI) scan in a patient with Conn syndrome showing a left adrenal adenoma.
Homogeneous, well-defined, 7-HU ovoid mass is seen in the right adrenal gland; this finding is diagnostic of a benign adrenal adenoma.

of 2

Author

Brian J Miles, MD, FACS Medical Director of Robotic Surgery, Houston Methodist Hospital; Clinical Professor, Department of Urology, Baylor College of Medicine; Professor of Urology, Weill Cornell Medical College

Brian J Miles, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society of Gene and Cell Therapy, American Society of Clinical Oncology, International Society of Urology, Harris County Medical Society, Society of Government Service Urologists, Washington Urologic Society, Society of University Urologists, American Medical Association, American Urological Association, Association of Military Surgeons of the US, Society of Urologic Oncology, Texas Medical Association, Texas Urological Society

Disclosure: Nothing to disclose.

Coauthor(s)

Mohit Khera, MD, MBA, MPH Assistant Professor of Urology, Scott Department of Urology, Baylor College of Medicine

Mohit Khera, MD, MBA, MPH is a member of the following medical societies: American Medical Association, American Urological Association, Texas Medical Association

Disclosure: Received honoraria from Auxilium for speaking and teaching; Received honoraria from Coloplast for speaking and teaching; Received honoraria from American Medical Systems for speaking and teaching.

Edward C Schatte, MD Urologist, Adult and Pediatric Urology of Houston

Edward C Schatte, MD is a member of the following medical societies: American Urological Association

Disclosure: Received consulting fee from Pfizer for speaking and teaching; Received consulting fee from Astellas for speaking and teaching; Received consulting fee from Glaxo Smith Kline for speaking and teaching; Received consulting fee from novartis for speaking and teaching; Received consulting fee from Watson for speaking and teaching.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Bradley Fields Schwartz, DO, FACS Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine

Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoscopic and Robotic Surgeons, Society of University Urologists

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Endourological Society Board of Directors; President Elect North Central Section of the American Urological Association<br/>Serve(d) as a speaker or a member of a speakers bureau for: Cook Medical.

Additional Contributors

John S Colen, MD Urologist, Kelsey-Sebold Clinic

John S Colen, MD is a member of the following medical societies: American Medical Association

Disclosure: Nothing to disclose.