Treating adrenal cancer by stage

Treating adrenal cancer by stage

Stages I and II

Surgery is the main treatment for stage I and stage II adrenal cancer. The entire adrenal gland will be removed. Since a person has 2 adrenal glands, removal of the diseased one does not generally cause problems for the patient. If nearby lymph nodes are enlarged, they will be removed as well and checked to see if they contain cancer cells. Most surgeons do not remove these lymph nodes if their size is normal. In many cases, no further treatment may be necessary. If the tumor was not removed completely, treatment with radiation.

These treatments may also be given if the tumor has a higher chance of coming back later because it was large or appears to be growing fast (when looked at under the microscope). When treatment is given after surgery has removed all visible cancer, it is called adjuvant therapy. The goal of adjuvant therapy is to kill any cancer cells that may have been left behind but are too small to be seen. Killing these cells lowers the chance of the cancer coming back later.

Stage III

Surgery is also the main treatment for stage III adrenal cancer. The goal of surgery is to remove all of the cancer. The adrenal gland with the tumor is always removed, and the surgeon might also need to remove some tissue around the adrenal gland, including part (or all) of the nearby kidney and part of the liver. The lymph nodes near the adrenal gland will also be removed. After surgery, adjuvant treatment with radiation and/or mitotane may be given to help keep the cancer from coming back.

Stage IV

If it is possible to remove all of the cancer, then surgery may be done. When the cancer has spread to other parts of the body, it usually cannot be cured with surgery. Some doctors may still recommend surgery to remove as much of the tumor as possible. This type of surgery is called debulking. Removing most of the cancer may help reduce symptoms by lowering the production of hormones. Radiation therapy may also be used to treat any areas of cancer that are causing symptoms. For example, radiation can help people when cancer that has spread to the bones is causing pain. Mitotane therapy is also an option. Treatment may begin right away or it may be postponed until the cancer is causing symptoms. Other chemotherapy (chemo) drugs may also be used.

Recurrent adrenal cancer

Cancer is called recurrent when it comes back after treatment. Recurrence can be local (in or near the same place it started) or distant (spread to organs such as the lungs or bone). Local recurrence may be treated with surgery to remove the cancer. This is more likely to be done if all of the cancer can be removed. Distant recurrence is treated like stage IV disease. Debulking surgery may be done to relieve symptoms. People with recurrent disease are often treated with mitotane. They may also receive chemo and/or radiation therapy. If the mitotane doesn't work or cannot be tolerated, other drugs can be given to lower hormone production.

Most of the time, these treatments provide only temporary help because the tumor will eventually continue to grow. When this happens and these treatments are no longer helping, treatment aimed at providing as good a quality of life as possible may be the best choice. The best drugs to treat pain are morphine and other narcotic drugs. Many studies have shown that taking morphine as directed for pain does not mean a person will become addicted.

There are many other ways your doctor can help maintain your quality of life and control your symptoms. This means that you must tell your doctor how you are feeling and what symptoms you are having. Many patients don't like to disappoint their doctors by telling them they are not feeling well. This does no one any good.

ADRENAL CANCER TREADMENT

General treatment information

After the cancer is diagnosed, your doctor will discuss your treatment options with you. It is important to take time and think about all of the choices. In choosing a treatment plan, factors to consider include your overall physical health and the stage of the cancer. Sometimes it is a good idea to get a second opinion. A second opinion can provide more information and help you feel more confident about the treatment plan that is chosen. Another reason for people with adrenal cortical cancer to get a second opinion is that, because these cancers are so rare, only large cancer centers will have much experience in treating them.

The main types of treatment for adrenal cancer are:

• Surgery
• Radiation
• Chemotherapy
• Other drugs

Depending on the type and stage of your cancer, you may need more than one type of treatment. Doctors on your cancer treatment team might include:

• A surgeon: a doctor who uses surgery to treat cancers or other problems
• An endocrinologist: a doctor who treats diseases in glands that secrete hormones
• A radiation oncologist: a doctor who uses radiation to treat cancer
• A medical oncologist: a doctor who uses chemotherapy and other medicines to treat cancer

Many other specialists may be involved in your care as well, including nurse practitioners, nurses, psychologists, social workers, rehabilitation specialists, and other health professionals. The next few sections describe the types of treatment used for adrenal cancers. 

It is important to discuss all of your treatment options, including their goals and possible side effects, with your doctors to help make the decision that best fits your needs. It’s also very important to ask questions if there is anything you’re not sure about.

Thinking about taking part in a clinical trial

Clinical trials are carefully controlled research studies that are done to get a closer look at promising new treatments or procedures. Clinical trials are one way to get state-of-the art cancer treatment. In some cases they may be the only way to get access to newer treatments. They are also the best way for doctors to learn better methods to treat cancer. Still, they are not right for everyone.

If you would like to learn more about clinical trials that might be right for you, start by asking your doctor if your clinic or hospital conducts clinical trials. You can also call our clinical trials matching service at 1-800-303-5691 for a list of studies that meet your medical needs,

Considering complementary and alternative methods

You may hear about alternative or complementary methods that your doctor hasn’t mentioned to treat your cancer or relieve symptoms. These methods can include vitamins, herbs, and special diets, or other methods such as acupuncture or massage, to name a few.

Complementary methods refer to treatments that are used along with your regular medical care. Alternative treatments are used instead of a doctor’s medical treatment. Although some of these methods might be helpful in relieving symptoms or helping you feel better, many have not been proven to work. Some might even be dangerous.

Be sure to talk to your cancer care team about any method you are thinking about using. They can help you learn what is known (or not known) about the method, which can help you make an informed decision. 

Help getting through cancer treatment

Your cancer care team will be your first source of information and support, but there are other resources for help when you need it. Hospital- or clinic-based support services are an important part of your care. These might include nursing or social work services, financial aid, nutritional advice, rehab, or spiritual help.

The American Cancer Society also has programs and services – including rides to treatment, lodging, support groups, and more – to help you get through treatment. Call our National Cancer Information Center at 1-800-227-2345 and speak with one of our trained specialists on call 24 hours a day, every day.

The treatment information given here is not official policy of the American Cancer Society and is not intended as medical advice to replace the expertise and judgment of your cancer care team. It is intended to help you and your family make informed decisions, together with your doctor. Your doctor may have reasons for suggesting a treatment plan different from these general treatment options. Don't hesitate to ask him or her questions about your treatment options.

Chemotherapy for adrenal cancer

Chemotherapy for adrenal cancer

Systemic chemotherapy (chemo) is giving drugs into a vein or by mouth (in pill form). These drugs enter the bloodstream and reach throughout the body, making this treatment useful for cancer that has spread (metastasized) to organs beyond the adrenal gland. Chemo does not work very well in adrenal cancer, so it is most often used for adrenal gland cancer that has become too widespread to be removed with surgery. Chemo does not cure adrenal cancer.

Mitotane

The drug most often used for people with adrenal cancer is called mitotane. Mitotane blocks hormone production by the adrenal gland and also destroys both adrenal cancer cells and healthy adrenal tissue. This drug can suppress the usual adrenal steroid hormone production from your other, normal adrenal gland. This can lead to low levels of cortisol and other hormones, which can make you feel weak and sick. If this occurs, you will need to take steroid hormone pills to bring your hormone levels up to normal. Mitotane can also alter levels of other hormones, such as thyroid hormone or testosterone. If that occurs, you would need drugs to replace these hormones as well.

Sometimes mitotane is given for a period of time after surgery has removed all the (visible) cancer. This is called adjuvant therapy and is meant to kill any cells that were left behind, but were too small to see. Giving the drug this way may prevent or delay the return of the cancer.

If the cancer has not been completely removed by surgery or has come back, mitotane will shrink the cancer in some patients. On average, the response lasts about one year, but can be longer for some patients.

Mitotane is particularly helpful for people with adrenal cancers who have problems caused by excessive hormone production. Even when it doesn't shrink the tumor, mitotane can reduce abnormal hormone production and relieve symptoms. About 80% of patients with excess hormone production are helped by mitotane. This drug can cause major side effects, however. The most common are nausea, vomiting, diarrhea, rashes, confusion, and sleepiness. Sometimes lower doses of the drug can still be effective and cause fewer side effects. This drug is a pill and is taken 3 to 4 times a day. Like other types of chemo, treatment with mitotane needs to be supervised closely by a doctor.

Other chemo drugs used for adrenal cancer

Other chemo drugs are sometimes combined with mitotane to treat advanced adrenal cancer. The drugs used most often are:

• The combination of cisplatin, doxorubicin (Adriamycin®), and etoposide (VP-16) plus mitotane
• Streptozocin plus mitotane

Some other chemo drugs are used less often, such as:

• Paclitaxel (Taxol®)
• 5-fluorouracil (5-FU)
• Vincristine (Oncovin®)

These drugs may be given in different combinations and are often given with mitotane.

Chemotherapy drugs kill cancer cells but also damage some normal cells, which can cause some side effects. Careful attention must be given to avoid or minimize chemo side effects. Side effects from chemo depend on the type of drugs, the amount taken, and the length of treatment. Common side effects might include:

• Nausea and vomiting
• Loss of appetite
• Loss of hair
• Hand and foot rashes
• Mouth sores
• Low blood counts

Because chemotherapy can damage the blood-producing cells of the bone marrow, patients may have low blood cell counts. This can lead to:

• Increased risk of infection (due to a shortage of white blood cells)
• Bleeding or bruising after minor cuts or injuries (due to a shortage of blood platelets)
• Anemia (due to low red blood cell counts)

Most side effects disappear once treatment is stopped. Hair will grow back after treatment ends, though it might look different. There are good treatments for many of the side effects of chemotherapy. For example, very good drugs are available to prevent or reduce nausea and vomiting.

Some chemo side effects can last a long time or even be permanent. For example, doxorubicin can damage the heart muscle over time. Your health care team will watch the dose of this drug closely, to make sure that the dose isn't high enough to cause this damage. Cisplatin and paclitaxel can both cause nerve damage (called neuropathy), leading to painful tingling and numbness in the hands and feet. This tends to get better after chemo stops, but it might not go away completely.

Radiation therapy for adrenal cancer

Radiation therapy uses high-energy radiation to kill cancer cells. External beam radiation therapy focuses radiation on the cancer from a machine outside the body. Treatments are often given once or twice a day, 5 days a week for several weeks. Each treatment lasts only a few minutes, and is similar to having a regular x-ray test. As with a diagnostic x-ray, the radiation passes through the skin and other tissues before it reaches the tumor. The actual radiation exposure time is very short, and most of the treatment time is spent precisely positioning the patient so that the radiation is aimed accurately at the cancer.

Brachytherapy (internal radiation therapy) uses small pellets of radioactive material placed next to or directly into the cancer, sometimes in thin plastic tubes. The tubes containing the pellets are left in place for a few days and then removed. The actual time is determined by the strength of the radioactive pellets and the size of the tumor. This type of radiation is not often used to treat adrenal cortical carcinoma.

Radiation therapy is not used often as the main initial treatment for adrenal cancer because the cancer cells are not easy to kill with x-rays. Radiation may be used after surgery to help keep the tumor from coming back. This is called adjuvant therapy. Radiation can also be used to treat areas of cancer spread, such as in the bones or brain.

Common side effects of radiation therapy include:

• Nausea and vomiting
• Diarrhea (if an area of the abdomen is treated)
• Skin changes in the area being treated, which can range from redness to blistering and peeling
• Hair loss in the area being treated
• Fatigue
• Low blood counts

RADIATION THERAPY SIDE EFFECTS

Radiation Therapy Effects

Radiation therapy can cause side effects by damaging normal, healthy cells near the cancer. Follow the links below to learn about the most common side effects from radiation therapy.

Taking care of yourself during radiation therapy

Radiation therapy can damage healthy body tissues in or near the area being treated, which can cause side effects. Many people worry about this part of their cancer treatment. Before treatment, talk with your cancer care team about what you might expect.

You need to take special care of yourself to protect your health during radiation treatment. Your cancer care team will give you advice based on your treatment plan and the side effects you might have.

Here are some general tips:

• Be sure to get plenty of rest. You may feel more tired than normal. Try to get good, restful sleep at night. Severe tiredness, called fatigue (fuh-TEEG), may last for several weeks after your treatment ends. See “Fatigue” in the “Common side effects of radiation therapy” section for more information.
• Eat a balanced, healthy diet. Depending on the part of your body getting radiation, your cancer care team may suggest changes in your diet. You can learn more about eating well in our booklet Nutrition for the Person With Cancer During Treatment: A Guide for Patients and Families.
• Tell your cancer care team about all medicines and supplements you are taking. Give your team a full list of everything you take and how often you take it, even things like aspirin, vitamins, or herbs. Don’t forget those you take only when you need them, such as sleep aids, antacids, headache remedies, and antihistamines.
• Take care of the skin in the treatment area. If you get external radiation therapy, the skin in the treatment area may become more sensitive or look and feel sunburned. Ask your cancer care team before using any soaps, lotions, deodorants, medicines, perfumes, cosmetics, powder, or anything else on the treated area. Some of these products may irritate sensitive skin. See “Skin problems” in the “Common side effects of radiation therapy” section for more on this.

How will I feel emotionally?

Many patients feel tired during radiation therapy, and this can affect emotions. You also might feel depressed, afraid, angry, frustrated, alone, or helpless.

We have a lot of information that can help you understand and manage the emotional changes that often come with cancer and cancer treatment. You can read more on website, www.cancer.org,

Getting involved with a support group and meeting other people with cancer may help you. Ask your cancer care team or call the American Cancer Society to learn more about ways to connect with others who share your problems and concerns.

Will side effects limit my activity?

Side effects might limit your ability to do some things. But what you can do will depend on how you feel. Talk to your cancer care team about this. Some patients are able to go to work or enjoy leisure activities while they get radiation therapy. Others find they need more rest than usual and can’t do as much. Your team may suggest you limit activities that might irritate the area being treated.

Side effects can vary.

Your cancer care team can tell you about your treatment, likely side effects, and things you need to do to take care of yourself. They can also talk to you about any other medical concerns you have. Tell them about any changes in the way you feel and any side effects you have, including skin changes, tiredness, diarrhea, or trouble eating. Be sure that you understand any home care instructions and know whom to call if you have more questions. Also be sure you know what to do if you need help after office hours, in case you have problems at night or on the weekend.

Side effects vary from person to person and depend on the radiation dose, the part of the body being treated, and other factors. Some people have no side effects at all, while others have quite a few. There’s no way to know who might have side effects.

How long do side effects last?

Radiation therapy can cause early and late side effects.

• Early side effects are those that happen during or shortly after treatment. They’re usually gone within a few weeks after treatment ends.
• Late side effects can take months or even years to develop. They’re often (but not always) permanent.

The most common early side effects are fatigue (feeling tired) and skin changes. Other early side effects usually are related to the area being treated, such as hair loss and mouth problems when radiation treatment is given to the head.

Most side effects go away in time. In the meantime, there are ways to reduce the discomfort they may cause. If you have bad side effects, the doctor may stop your treatments for a while, change the schedule, or change the type of treatment you’re getting. Tell your cancer care team about any side effects you notice so they can help you with them. The information here can serve as a guide to handling some side effects, but it can’t replace talking with your team about what’s happening to you.

People often become discouraged about how long their treatment lasts or the side effects they have. If you feel this way, talk to your cancer care team. If needed, they should be able to suggest ways to help you feel better.

Radioprotective drugs

Doctors look for ways to reduce side effects caused by radiation therapy while still using the doses needed to kill cancer cells. One way to reduce side effects is by using radioprotective (RAY-dee-o pro-TEK-tiv) drugs. These are drugs that are given before radiation treatment to protect certain normal tissues in the treatment area. The one most commonly used today is amifostine. This drug may be used in people with head and neck cancer to reduce the mouth problems caused by radiation therapy.

Radioprotective drugs are an active area of research. At this time not all doctors agree how these drugs should be used in radiation therapy. These drugs have their own side effects, too, so be sure you understand what to look for.

CHEMO SIDE EFFECTS

What causes side effects?

Cancer cells tend to grow fast, and chemo drugs kill fast-growing cells. But because these drugs travel throughout the body, they can affect normal, healthy cells that are fast-growing, too. Damage to healthy cells causes side effects. Side effects are not always as bad as you might expect, but many people worry about this part of cancer treatment.

The normal cells most likely to be damaged by chemo are blood-forming cells in the bone marrow; hair follicles; and cells in the mouth, digestive tract, and reproductive system. Some chemo drugs can damage cells in the heart, kidneys, bladder, lungs, and nervous system. In some cases, medicines can be given with the chemo to help protect the body’s normal cells.

What should I know about side effects?

• Every person doesn’t get every side effect, and some people get few, if any.
• The severity of side effects (how bad they are) varies greatly from person to person. Be sure to talk to your doctor and nurse about which side effects are most common with your chemo, how long they might last, how bad they might be, and when you should call the doctor’s office about them.
• Your doctor may give you medicines to help prevent some side effects before they happen.
• Some types of chemo cause long-term side effects, like heart or nerve damage or fertility problems. Still, many people have no long-term problems from chemo. Ask your doctor about the long-term risks of the chemo drugs you’re getting.
• While side effects can be unpleasant, they must be weighed against the need to kill the cancer cells.

How long do side effects last?

Most side effects slowly go away after treatment ends because the healthy cells recover over time. The time it takes to get over some side effects and regain energy varies from person to person. It depends on many factors, including your overall health and the drugs you were given.

Many side effects go away fairly quickly, but some may take months or even years to completely go away. Sometimes the side effects can last a lifetime, such as when chemo causes long-term damage to the heart, lungs, kidneys, or reproductive organs. Certain types of chemo sometimes cause delayed effects, such as a second cancer that may show up many years later.

People often become discouraged about how long their treatment lasts or the side effects they have. If you feel this way, talk to your doctor. You may be able to change your medicine or treatment schedule. Your doctor or nurse also may be able to suggest ways to reduce any pain and discomfort you have.

What are common side effects?

Most people worry about whether they will have side effects from chemo, and, if so, what they’ll be like. Here’s a review of some of the more common side effects caused by chemotherapy. We also share some tips on how you can manage them.

STAGE AND SURVIVAL RATES OF ADRENAL CANCER

STAGE OF ADRENAL CANCER

Staging is the process of finding out how far the cancer has spread. It's very important because treatment options and the course of the disease as well as prognosis (outlook) are determined by the stage of the cancer. Two major staging systems are used: the American Joint Committee on Cancer (AJCC) TNM staging system and the ENSAT (European Network for the Study of Adrenal Tumors) staging system. Both are based on the same TNM categories. They differ on how they combine those categories to determine the final stage (this is known as stage grouping).

TNM describes 3 key pieces of information:

• T indicates the size of the main (primary) tumor and whether it has grown into nearby areas.
• N describes how much the cancer has spread to nearby (regional) lymph nodes. Lymph nodes are small bean-shaped collections of immune system cells that are important in fighting infections.
• M indicates whether the cancer has spread (metastasized) to other organs of the body (the most common site is the liver).

Numbers or letters appearing after T, N, and M provide more details about each of these factors. The numbers 0 through 4 indicate increasing severity. The letter X means cannot be assessed because the information is not available.

Once the values for T, N, and M are determined, they are combined together to decide the stage. This is called stage grouping.

T categories for adrenal cancer

T1: the tumor is 5 cm (about 2 inches) or less in size and it has not grown into tissues outside the adrenal gland

T2: the tumor is greater than 5 cm (2 inches) in size and it has not grown into tissues outside the adrenal gland

T3: the tumor is growing in the fat that surrounds the adrenal gland. The tumor can be any size.

T4: the tumor is growing into nearby organs, such as the kidney, pancreas, spleen, and liver. The tumor can be any size.

N categories

N0: the cancer has not spread to nearby lymph nodes

N1: the cancer has spread to nearby lymph nodes

M categories

M0: the cancer has not spread to distant organs or tissues (like liver, bone, brain)

M1: the cancer has spread to distant sites

Stage groupings for adrenal cancer in the AJCC system

Stage I

T1, N0, M0: The cancer is smaller than 5 cm (2 inches) and has not grown into surrounding tissues or organs. The cancer has not spread to lymph nodes (N0) or other body parts (M0).

Stage II

T2, N0, M0: The cancer is larger than 5 cm (2 inches) but still has not grown into surrounding tissues or organs. The cancer has not spread to lymph nodes (N0) or other body parts (M0).

Stage III

Either of the following:

T1 or T2, N1, M0: The tumor can be any size but it has not started growing outside the adrenal gland (T1 or T2). The cancer has spread to nearby lymph nodes (N1) but not to distant sites (M0).

OR

T3, N0, M0: The cancer has grown into the fat outside the adrenal gland (T3). It has not spread to nearby lymph nodes (N0) or to distant sites (M0).

Stage IV

Either of the following:

T3, N1, M0: the cancer has grown into the fat outside of the adrenal gland (T3) and it has spread to nearby lymph nodes (N1); it has not spread to distant body sites (M0)

OR

T4, N0 or N1, M0: the cancer has grown from the adrenal gland into organs or tissues nearby (T4) It may (N1) or may not (N0) have spread to nearby lymph nodes, but it has not spread to distant sites (M0)

OR

Any T, any N, M1: The cancer has spread to distant sites (M1). It can be any size and may or may not have spread to nearby tissues or lymph nodes.

Stage groupings for adrenal cancer in the ENSAT system

In the ENSAT system, stages I and II are the same as they are in the AJCC system. Stages III and IV are different.

Stage III

Either

T3 or T4, N0, M0: the cancer has grown into the fat outside of the adrenal gland (T3) or into nearby organs or tissues (T4). It has not spread to nearby lymph nodes (N0) or to distant sites (M0).

OR

Any T, N1, M0: the cancer can be any size and may have grown into nearby tissues (any T). It has spread to nearby lymph nodes (N1), but not to distant sites (M0).

Stage IV

Any T, any N, M1: The cancer has spread to distant sites (M1). It can be any size and may or may not have spread to nearby tissues or lymph nodes.

Survival rates by stage for adrenal cancer

Survival rates are often used by doctors as a standard way of discussing a person's prognosis (outlook). Some patients with cancer want to know the survival statistics for people in similar situations, while others might not find the numbers helpful, or not want to know them. If you decide you don’t want to know them,

The 5-year survival rate refers to the percentage of patients who live at least 5 years after their cancer is diagnosed. Of course, many people live much longer than 5 years (and many are cured).

Five-year relative survival rates assume that some people will die of other causes and compare the observed survival with that expected for people without the cancer. This is a better way to see the impact of the cancer on survival.

In order to get 5-year survival rates, doctors have to look at people who were treated at least 5 years ago. Improvements in treatment since then may result in a more favorable outlook for people now being diagnosed with adrenal cortical cancer.

Survival rates are often based on previous outcomes of large numbers of people who had the disease, but they cannot predict what will happen in any particular person's case. Many other factors besides stage can affect a person's outlook, such as the grade of their cancer, the treatment they receive, their age, and overall health. Your doctor can tell you how the numbers below may apply to you, as he or she is familiar with the aspects of your particular situation.

The numbers below come from the National Cancer Institute's SEER database, and are based on people diagnosed between 1988 and 2001. The SEER database does not list survival statistics by AJCC or ENSAT stages. Instead, it divides patients into 3 groups: localized, regional, and distant. Localized means that the cancer hasn't grown outside of the adrenal gland at diagnosis (like stages I and II). Regional means that the cancer has grown into nearby tissues or has spread to nearby lymph nodes (like ENSAT stage III). Distant means that the cancer has spread further to distant sites (like ENSAT stage IV).

Stage	5-year Relative Survival
Localized	65%
Regional	44%
Distant	7%

DIAGNOSE OF ADRENAL CANCER

DIAGNOSE OF ADRENAL CANCER

Medical history and physical exam

The first step is for the doctor to take your complete medical history to check for any symptoms. Your doctor will want to know if anyone in your family has had adrenal cancer or any other type of cancer. Your doctor will also ask about your menstrual or sexual function and about any other symptoms that you may be having. A physical exam will give other information about signs of adrenal gland cancer and other health problems. Your doctor will thoroughly examine your abdomen for evidence of a tumor (or mass).

Your blood and urine will be tested to look for high levels of the hormones produced by some adrenal adenomas and carcinomas. If an adrenal tumor or cancer is suspected, imaging tests will be done to look for a tumor. These tests can also help see if it has spread.

If a mass is seen on an imaging test and it is likely to be an adrenal cancer, doctors will recommend surgery to remove the cancer. Generally, doctors do not recommend a biopsy (removing a sample of the tumor to look at under the microscope to see if it is cancer) before surgery to remove the tumor. That is because doing a biopsy can increase the risk that an adrenal cancer will spread outside of the adrenal gland.

Imaging tests

Chest x-ray

This can show if the cancer has spread to the lungs. It may also be useful to determine if there are any serious lung or heart diseases.

Ultrasound

Ultrasound tests use sound waves to take pictures of parts of the body. A device called a transducer produces the sound waves, which are reflected by tissues of nearby organs. The pattern of sound wave echoes is detected by the transducer and analyzed by a computer to create an image of these tissues and organs. This test can show if there is a tumor mass in the adrenal gland. It can also diagnose tumor masses in the liver if the cancer has spread there. In general, it is not used to look for adrenal tumors unless a CT scan isn’t able to be done.

Computed tomography (CT)

CT scans show the adrenal glands fairly clearly and often can confirm the location of the cancer. It can also help show whether your cancer has spread into your liver or other organs nearby. CT scans can also show lymph nodes and distant organs where metastatic cancer might be present. The CT scan can help determine if surgery is a good treatment option.

The CT scan is an x-ray procedure that produces detailed cross-sectional images of your body. CT scans take longer than regular x-rays. Instead of taking one picture, like a conventional x-ray, a CT scanner takes many pictures as the camera rotates around you. A computer then combines these pictures into an image of a slice of your body. The machine will take pictures of many slices of the part of your body that is being studied.

A CT scanner has been described as a large donut, with a narrow table in the middle opening. You will need to lie still on the table while the scan is being done. CT scans take longer than regular x-rays, and you might feel a bit confined by the ring while the pictures are being taken. Before any pictures are taken, you may be asked to drink 1 to 2 pints of a liquid called oral contrast. This helps outline the stomach and intestine to make abnormal areas easier to spot. You may also receive an IV line through which a different kind of contrast dye (IV contrast) is injected. This helps better outline structures such as blood vessels in your body.

The injection can cause some flushing (redness and a feeling of warmth that may last hours to days). A few people are allergic to the dye and get hives. Rarely, more serious reactions like trouble breathing and low blood pressure can occur. Medicine can be given to prevent and treat allergic reactions. Be sure to tell the doctor if you have ever had a reaction to any contrast material used for x-rays.

CT scans can also be used to precisely guide a biopsy needle into a suspected metastasis. For this procedure, called a CT-guided needle biopsy, the patient remains on the CT scanning table, while a radiologist moves a biopsy needle toward the location of the mass. CT scans are repeated until the doctors are sure that the needle is within the mass. A fine needle biopsy sample (tiny fragment of tissue) or a core needle biopsy sample (a thin cylinder of tissue about ½ inch long and less than 1/8 inch in diameter) is removed and examined under a microscope.

Positron emission tomography (PET)

In this test, radioactive glucose (sugar) is injected into the patient’s vein. Because cancer cells use sugar much faster than normal tissues, radioactivity will tend to concentrate in the cancer. A scanner can spot the radioactive deposits. This test can be helpful in spotting small collections of cancer cells and may be used to find cancer that has spread. It also may help in deciding if an adrenal tumor is likely to be benign or malignant (cancer).

A special type of PET scan is currently used only in research settings. It uses a radioactive form of a substance called metomidate. This substance seems to concentrate in adrenal cortical tissue, particularly adenomas and carcinomas. PET scanning with metomidate may in the future be helpful in distinguishing tumors that start in the adrenal cortex from cancers that started in other organs and then spread to the adrenals. It may also be helpful in finding adrenal cancer that has spread outside the adrenals.

Magnetic resonance imaging (MRI)

MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of tissue and by certain diseases. A computer translates the pattern of radio waves given off by the tissues into a very detailed image of parts of the body. Not only does this produce cross sectional slices of the body like a CT scanner, it can also produce slices that are parallel with the length of your body. For some MRI scans, a contrast material called gadolinium is injected into a vein (IV). MRI may sometimes provide more information than CT scans because it can better distinguish adrenal cancers from benign tumors.

MRI scans are particularly helpful in examining the brain and spinal cord. In people with suspected adrenal tumors, an MRI of the brain may be done to examine the pituitary gland. Tumors of the pituitary gland, which lies underneath the front of the brain, can cause symptoms and signs similar to adrenal tumors.

MRI scans are a little more uncomfortable than CT scans. First, they take longer. You have to be placed inside a tube, which is confining and can upset people who become anxious in tight spaces (claustrophobia). If you have problems with tight spaces, tell your doctor before your MRI. Medicine may be given before the scan to help with anxiety. If that doesn't work, the exam may be scheduled at an open MRI scanner. These machines are not so enclosing and so are easier for some patients, although the drawback is that the pictures may not be as good. The machine also makes a thumping noise that you might find disturbing. Some places will provide headphones with music to block this sound out.

Other tests

Laparoscopy

This procedure uses a laparoscope, a thin, flexible tube with a tiny video camera on the end. It is inserted through a small surgical opening in the patient's side to allow the surgeon to see where the cancer is growing. It can spot distant spread as well as enlarged lymph nodes. Sometimes it is combined with ultrasound to give a better picture of the cancer. Laparoscopy may be done to help predict whether it will be possible to completely remove the cancer by surgery. In addition to viewing adrenal tumors through the laparoscope, surgeons can sometimes remove small benign adrenal tumors through this instrument. This method is described in the section, “Surgery for adrenal cancer.”

Biopsy

Imaging tests may find tumors, but often the only way to know for sure that a tumor is cancer is to remove a sample of tumor tissue to look at under the microscope. This is called a biopsy. If a thin needle that only removes tiny bits of tissue is used, it is called a fine needle aspiration, or FNA. When a larger needle that removes a thin cylindrical core of tissue is used, it is called a core needle biopsy. In either case, the biopsy is often done using a CT scan or ultrasound to guide the tip of the needle into the tumor.

Since adrenal adenomas and cancers can look alike under the microscope, a biopsy may not be able to tell whether or not an adrenal tumor is cancerous. Also, a needle biopsy of an adrenal cancer can actually spread tumor cells. For these reasons, a biopsy is generally not done before surgery if an adrenal tumor's size and certain features seen on imaging tests suggest it is cancer. A work-up with blood tests for hormone production and imaging studies are more useful than biopsies in the diagnosis of adrenal cancer.

If the cancer appears to have metastasized (spread) to another part of the body such as the liver, then a needle biopsy of the metastasis may be done. If a patient is known to have an adrenal tumor and a liver biopsy shows adrenal cells are present in the liver, then the tumor is cancer.

In general, a biopsy is only obtained in a patient with adrenal cancer when there are tumors outside the adrenals and the doctor needs to know if these are spread (metastases) from an adrenal cancer or are caused by some other cancer or disease. Adrenal tumors are sometimes biopsied when the patient is known to have a different type of cancer (like lung cancer) and knowing that it has spread to the adrenal glands would alter treatment.

Tests for adrenal hormones

Blood and urine tests to measure levels of adrenal hormones are important in deciding whether a patient with signs and symptoms of adrenal cancer has the disease. For urine tests, you may be asked to collect all of your urine for 24 hours. Blood and urine tests are as important as imaging tests in diagnosing adrenal cancer. Doctors choose which tests to do based on the patient's symptoms. Doctors know which symptoms are associated with high levels of certain hormones, so they can focus on ways to look for the hormones most likely to be affected. Often doctors will check hormone levels even when symptoms of high hormone levels are not present. This is because symptoms of abnormal hormone levels can be very subtle and blood tests may even be able to detect changes in hormone levels before symptoms occur.

Tests for high cortisol levels

The levels of cortisol are measured in the blood and in the urine. If an adrenal tumor is making cortisol, these levels will be abnormally high. These tests may be done after giving the patient a dose of dexamethasone. Dexamethasone is a drug that acts like cortisol. If given to someone who does not have an adrenal tumor, it will decrease production of cortisol and similar hormones. In someone with an adrenal cortex tumor, these hormone levels will remain high after they receive dexamethasone. Blood levels of ACTH will also be measured to help distinguish adrenal tumors from other diseases that can cause high cortisol levels.

Tests for high aldosterone levels

The level of aldosterone will be measured and will be high if the tumor is making aldosterone. Also, high aldosterone leads to low levels of potassium and renin (a hormone produced by the kidneys) in their blood.

Tests for high androgen or estrogen levels

Patients with androgen-producing tumors will have high levels of dehydroepiandrosterone sulfate (DHEAS) or testosterone. Patients with estrogen-producing tumors will have high levels of estrogen in their blood.