The adrenal glands are triangular, orange-colored endocrine glands that sit atop both kidneys. They are primarily responsible for regulating the stress response, including the secretion of cortisol and adrenaline. The adrenal cortex secretes a variety of steroid hormones including cortisol, aldosterone, and testosterone. A tumor of the adrenal cortex of any kind can elevate steroid hormones and manifest a variety of clinical behaviors, such as anxiousness, and symptoms like the bruising and puffiness of Debbie’s upper chest.
Debbie had a functional tumor, the kind that results in endocrine disorders. But it was surgically curable.
The next day, one of my nurses caught me as I left an examining room. She told me that the radiologist was on the phone about Debbie.
“Dr. Norman,” the radiologist said, “this looks like an adrenal tumor.”
The next step was clear. I had referred Debbie to an endocrinologist to rule out disorders such as Cushing’s syndrome, a serious condition marked by weight gain (but not on the limbs), bruising, and even male-pattern hair growth in females. It was a possible diagnosis, but the endocrinologist quickly ruled it out.
Now, in order to move forward with our new information, we needed to determine whether the tumor was functional (hormonally active), nonfunctional, or malignant. The treatment for a hormonally active adrenal tumor was surgery. If the tumor was malignant, the treatment would depend on the cell type, spread, and location of the primary tumor.
The size of the tumor is considered an important predictive characteristic: Larger tumors are more likely to be malignant. Debbie’s was fairly small, a very good prognostic sign.
Expensive additional testing and invasive procedures are necessary to rule out the slight possibility of an early adrenocortical carcinoma, a rare form of cancer.
Luckily, Debbie had an adrenocortical adenoma—a “functional” tumor, meaning that it produces hormones including glucocorticoids, mineralcorticoids, and/or sex steroids. In doing so, such tumors can cause endocrine disorders that, among other things, feminize men or masculinize women. The good news is that functional adrenocortical adenomas are surgically curable.
The adrenal gland—no bigger than a walnut—has an effect on the body far out of proportion to its size. In most cases, adrenocortical adenomas are less than 2 centimeters in diameter and weigh less than 50 grams, or about 2 ounces.
Now was the time to consult my friendly neighborhood surgeon. Unlike the characters in House, doctors in the real world welcome other physicians to do surgical procedures such as the unilateral adrenalectomy that Debbie required. The surgery is usually a minimally invasive laparoscopic procedure.
After the adrenocortical adenoma was removed, Debbie improved greatly. “I feel a lot more like Debbie again,” she told me. Her disposition was back to normal, and before long she had a new job and began losing some of the excess weight and hair.
I was also happy that, as she returned to an active life, she promised to take my advice about using sunblock to prevent the kind of skin cancers that had brought her to my office in the first place.
Robert Norman is a dermatologist based in Tampa, Florida. The cases in Vital Signs are real, but names and certain details have been changed.
