Presentation, disease progression and outcomes of adrenal gland metastases

Abstract

Objective: Data on the presentations and outcomes of patients with adrenal gland metastases are limited. Our objectives were to characterize the prevalence of adrenal metastases subtypes and investigate how varying clinical presentations affect disease progression, development of primary adrenal insufficiency (PAI) and mortality. Design: Single institution tertiary centre, retrospective cohort study from 1997 to 2020. Patients and Measurements: Adult patients with adrenal metastases. Clinical, radiologic and biochemical presentations and outcomes were reviewed. Results: Of 579 patients (62.3% men, median age 67 years [range 25-92]) with adrenal metastases (median tumour size of 30 mm [range 5-200]), 339 (58.5%) were discovered during cancer staging, 210 (36.3%) were found incidentally, and 29 (5.0%) based on symptoms. Tumours originated from the lung (226, 39.0%), genitourinary (GU) (160, 27.6%), gastrointestinal (GI) (79, 13.6%) and other (114, 19.7%) organ systems. Bilateral metastases were found in 140 (24.2%) patients at the time of initial diagnosis, and 249 (43.0%) had bilateral disease throughout the study course. PAI developed in 12.4% of patients with bilateral disease and was associated with larger tumour size. Median follow-up time was 14 months (range 0-232), and 442 (76.3%) patients died. Higher mortality was independently associated with older age, adrenal metastases originating from the lung, bilateral disease, and the absence of adrenalectomy. Conclusions: Adrenal gland metastases originated most commonly from lung, GU and GI malignancies. Bilateral adrenal metastases occurred in 43% of patients, and PAI occurred in 12.4% of those with bilateral disease, warranting further case detection strategies.

The epidemiology of primary and secondary adrenal malignancies and associated adrenal insufficiency in hospitalised patients: an analysis of hospital admission data, NSW, Australia

“…Males and older age groups were more commonly affected, which is consistent with the epidemiology of the underlying primary malignancies and the generally increased prevalence of AI in the older population [ 21 ]. This is in contrast to the proportion of AI patients diagnosed in a recent case series by Mao et al, who identified that, among patients with bilateral metastatic disease, 12.4% of patients had primary AI [ 3 ] and to the estimated prevalence of 3–8% in a recent systematic review and meta-analysis [ 4 ]. The relative rarity of an AI diagnosis in this study may reflect lower levels of diagnosis or recording of this comorbidity in hospitalised patients.…”

“…The reasons for the observed 74.8% increase in admission rates associated with a metastatic adrenal malignancy, which has not been documented elsewhere, could not be determined in this analysis. However, it is likely that, in the absence of a substantial increase in diagnoses for relevant primary malignancies during this time, the greater use of imaging, both for unrelated symptoms, which was the source of 36.3% of such diagnoses in one recent case series [ 3 ]; and staging and follow-up, which characterises the modern management of cancer and was responsible for 58.5% of diagnoses in the same series, [ 3 ] may have contributed to an increase in identification of adrenal metastases. By comparison, there were fewer admissions with a primary adrenal malignancy, which showed no clear trend over the same time frame, despite the well documented increase in incidental diagnoses of (mostly benign) adrenal tumours, as a consequence of the increase in imaging for symptoms that are unrelated to adrenal disorders [ 1 , 4 ].…”

“…Most adrenal tumours are small, benign, non-functioning adrenocortical adenomas, which increase in incidence with advancing age [ 1 , 4 ]. By comparison, malignant tumours of the adrenal gland are less common, accounting for 2.8 to 6.7% of all adrenal neoplasms [ 3 , 5 – 7 ] and are most often due to metastatic spread to the adrenals from a primary malignant tumour in another organ, with common primary sites being lung, breast, melanoma and, less frequently, carcinomas of the stomach, colon, rectum, and pancreas [ 3 , 7 – 9 ]. In contrast to the incidence of secondary malignancies, primary adrenal malignancies are rare, have an estimated incidence of 7.4/million [ 1 ], and are most often adrenocortical carcinomas (ACC), which occur at approximately 1–2 cases per million per year [ 10 ].…”

“…Despite the relative rarity of AI in patients with an adrenal malignancy, early identification of characteristic AI symptoms, which can be readily treated with glucocorticoid replacement therapy, with or without additional mineralocorticoid, can improve quality of life and avert a potentially fatal AC [ 3 , 7 ]. However, there is limited information available on the incidence of AI in patients with adrenal malignancies, especially among those with adrenal metastases [ 4 ], to guide clinical management of patients.…”

Nonseminomatous Germ-Cell Tumor Presenting as Bilateral Adrenal Masses

“…18 Adrenal metastasis of genitourinary primary tumors has been demonstrated to have the highest prevalence of bilateral disease. 19 In our case, the patient had bilateral adrenal metastasis from an extragonadal germ-cell tumor; hence, locating the primary tumor was challenging.…”