Experts: All Adrenal Tumors Should Be Evaluated

As an on-the-go mother of two equally on-the-go preschoolers, Yessenia Paez was accustomed to dealing with common parenting stress. But when 24/7 anxiety, heart palpitations, hand tremors and chronic headaches became the norm for the better part of a year, she knew something more was at play.

A car accident and follow-up CT scan to check for related injuries pinpointed the cause of her symptoms: a rare tumor called a pheochromocytoma in one of her two adrenal glands.

Adrenal glands sit on top of each kidney and produce hormones that control various functions in the body. The pheochromocytoma, a type of adrenal tumor (also called an adrenal nodule or adrenal adenoma), was not cancerous but was producing excess hormones that were causing Paez’s symptoms. Left untreated, pheochromocytomas have the potential to become cancerous and also can produce stress hormones like adrenaline that can lead to a severe increase in blood pressure and risk of heart attack or stroke.

Paez quickly sought out experts in the treatment of adrenal tumors and found Cedars-Sinai specialists Anat Ben-Shlomo, MD, an endocrinologist and associate professor of Medicine, and Yufei Chen, MD, an endocrine surgeon and assistant professor of Surgery in the Department of Surgery. The physicians are co-directors of Cedars-Sinai’s Multidisciplinary Adrenal Program, which offers the complete spectrum of care and treatment for patients with adrenal tumors.

While most adrenal tumors are harmless, some can cause adrenal disorders and symptoms that should be addressed by a skilled team.

“We respond with appropriate treatment recommendations based on each patient’s individual needs,” Chen said. “We collaborate between endocrinology and surgery, and we involve other subspecialties, including genetics, cardiology, pediatrics, pathology, interventional radiology, radiology and oncology, as needed. The multidisciplinary aspect of our program is unique.” 

Ben-Shlomo called the program a “one-stop shop” that benefits both patients and physicians.

“A powerful benefit of our program is that the patient doesn’t need to go all over the place visiting doctors—we have everything required to address an adrenal tumor, and all physicians on the patient’s care team are in constant communication,” she said. “Some patients with adrenal tumors will need treatment and monitoring for the rest of their lives, and we’re here for them for the duration.”

Ben-Shlomo reviewed Paez’s CT scan, ordered bloodwork and a urine test, and referred Paez to Chen to discuss surgery to remove the tumor and alleviate her symptoms.

Paez’s experience—having a noncancerous adrenal tumor discovered incidentally through unrelated imaging—is the norm. And while pheochromocytomas are not common, adrenal tumors overall are being discovered more commonly as people undergo imaging scans more frequently.

“About 4% of all imaging scans reveal an adrenal tumor,” Ben-Shlomo said. “And, because we human beings tend to grow nodules as we get older, that percentage can increase to 10% as we age. That’s a significant amount.”

Most adrenal tumors are “nonfunctioning,” meaning they do not produce excess hormones or cause symptoms. Although nonfunctioning tumors don’t require long-term monitoring, Ben-Shlomo and Chen encourage all patients with an adrenal tumor to be evaluated by a specialist.

“An imaging report will often note a ‘benign-appearing adrenal adenoma,’ and the word ‘benign’ can lead to the tumor being overlooked,” Ben-Shlomo said. “Instead, there is a real need for a functional evaluation by an endocrinologist and perhaps a surgeon. Every tumor should be evaluated for size, shape and functionality because they can lead to serious and sometimes life-threatening diseases. Not all of them need to be removed, but they may need to be monitored in case they grow or symptoms arise.”

By the time Diana Wan found Cedars-Sinai’s Multidisciplinary Adrenal Program, she had been facing infertility, “off-the-charts” high cholesterol, high blood pressure, uncharacteristic weight gain and prediabetes for more than a year. Despite exercising consistently and eating well, her health was not improving. One day she experienced sudden, excruciating, abdominal pain, which led to a CT scan. The scan revealed a benign-appearing adrenal tumor.

Ben-Shlomo diagnosed Wan with adrenal Cushing’s syndrome—a rare disease caused by an adrenal tumor’s production of too much cortisol, a steroid hormone that regulates metabolism, blood pressure, blood sugar, stress and more. Cushing’s syndrome causes many of the symptoms Wan was experiencing, including weight gain, high blood pressure and infertility. 

“You’re so lucky that we found this when we did,” Ben-Shlomo told Wan. “It’s very bad for your body, and it will worsen over time.”

Chen removed Wan’s adrenal gland and today, nearly a year later, she no longer has Cushing’s syndrome. Her experience reinforces the benefits of having every adrenal tumor expertly evaluated.

“A lot of patients have their lives dramatically changed post-surgery,” Chen said. “Just a bit of cortisol over-secretion, for example, can lead to weight gain and metabolic syndrome, which increases the risk of heart disease, diabetes, stroke, bone loss, anxiety and depression. If this is an issue for years, symptoms worsen, leading to early mortality. Aldosterone over-secretion, another adrenal hormone, can lead to hypertension and low potassium and is associated with arrhythmias, sleep apnea and fatigue. When we’re able to remove certain hormone-producing tumors, some patients can be completely cured of related conditions.”

Wan, who continues to see Ben-Shlomo for follow-up monitoring, said, “I had complete trust in my team at Cedars-Sinai throughout the process, and it is comforting to know that I was—and continue to be—in good hands there.”

Paez’s symptoms also improved after surgery. Chen removed her adrenal gland laparoscopically, through tiny incisions in the abdomen, during a minimally invasive procedure known as an adrenalectomy. Her tumor was 6 centimeters—adrenal tumors over 4 centimeters are considered large and have an increased risk of being cancerous. Other removal options include robotic surgery, retroperitoneoscopic “through-the-back” surgery, and subtotal or partial adrenalectomy, which only removes the tumor. Most are done on an outpatient basis.

“The tumor is gone, my bloodwork is normal, and everything is under control,” Paez said. “I’m grateful for Dr. Chen and Dr. Ben-Shlomo, who worked together as a team from my very first appointment and who will continue to monitor me in the coming years.”

Read more on the Cedars-Sinai Blog: Debunking Adrenal Fatigue