Efficient management of adrenal tumors

A retrospective analysis was carried out on 121 patients with primary adrenal tumors operated on at 2 Vancouver hospitals between the years 1970 and 1990. The purpose of the study was to identify discriminating factors between the various diagnoses in order to minimize both the time and the cost of the investigative process. There were 57 cortical adenomas, 35 pheochromocytomas, 15 carcinomas, 8 cases of cortical hyperplasia, and 6 miscellaneous tumors. The mean time from the onset of symptoms to diagnosis of those patients presenting with an identifiable syndrome was 48.3 months. Those with a hypertensive syndrome presented significantly later than those with Cushing's syndrome (57.7 months versus 22.8 months, p < 0.01). There was a significant delay in diagnosis in those patients with hypertension on the basis of an aldosteronoma as compared with those with hypertension secondary to a pheochromocytoma (75.4 months versus 36.1 months, p = 0.02). Cortical carcinomas were significantly larger than benign cortical tumors (12.7 cm versus 5.5 cm). No malignant neoplasm measured less than 5 cm in diameter. Diagnostic sensitivity for intravenous pyelogram (IVP) was 59%, for ultrasound 71%, for venography 50%, for meta-iodobenzylguanidine (MIGB) (pheochromocytoma only) 80%, and for angiography 70%. However, for those patients with adrenal carcinomas, angiography was positive in 100% of cases. Computed tomography (CT) was the most sensitive localizing investigation with a sensitivity of 98%. While other localizing techniques were less sensitive than CT, they may still play a useful role in selected situations. Factors causing delay in diagnosis and the role of the various imaging modalities are discussed.