Urology · KIMS Secunderabad
Adrenal Mass — What It Means When a Scan Shows a Growth on Your Adrenal Gland
An adrenal mass — a growth on one or both of the adrenal glands, which sit atop the kidneys — is one of the most common incidental findings on abdominal CT and MRI scans. These lesions are found in approximately 4 to 5% of all abdominal CT scans performed for any reason, and the prevalence increases with age. The majority are benign, non-functioning adenomas — small collections of adrenal cortical cells with no hormonal activity and no malignant potential. However, a proportion are hormonally active (producing excess cortisol, aldosterone, or adrenaline) or malignant, and these require specific investigation and treatment.
The systematic evaluation of an adrenal mass — using specific CT characteristics, hormonal blood and urine testing, and where indicated, surgical resection — is a well-established clinical pathway. At KIMS, every adrenal mass is evaluated by the urology and endocrinology teams using the European Society of Endocrinology guidelines, and robotic adrenalectomy (Da Vinci Xi or X) is performed for masses requiring surgery with minimal invasiveness and rapid recovery.
The key questions in adrenal mass evaluation
Two questions determine the management of every adrenal mass:
Is it hormonally active? Even a small adrenal mass can produce excess hormones that cause significant clinical consequences — hypertension, glucose intolerance, and cardiovascular risk from cortisol excess (subclinical Cushing's); severe paroxysmal hypertension and cardiovascular crisis from adrenaline excess (phaeochromocytoma); and secondary hypertension with hypokalaemia from aldosterone excess (Conn's syndrome / primary hyperaldosteronism). Hormonal testing is mandatory for every adrenal mass regardless of size.
Is it malignant? Most adrenal masses (above 80%) are benign cortical adenomas. Adrenocortical carcinoma (ACC) — a rare but aggressive malignancy — occurs in approximately 2% of adrenal masses. Adrenal metastases from lung, breast, colon, or kidney cancer are found in patients with a known primary cancer. CT characteristics — size, attenuation (HU), and washout kinetics — guide the assessment of malignancy risk.
CT characteristics — the Hounsfield Unit (HU) assessment
Below 10 HU on non-contrast CT
Almost certainly a benign lipid-rich adenoma. Malignancy risk below 2%. No further imaging required for masses below 4cm with this appearance.
10–20 HU on non-contrast CT
Lipid-poor adenoma or other benign mass — majority are still benign. CT washout protocol (absolute washout above 60% or relative washout above 40% at 15 minutes = adenoma).
Above 20 HU or indeterminate on non-contrast CT
Requires contrast-enhanced CT with washout calculation or MRI with chemical shift imaging to characterise. Masses with poor washout, irregular margins, or heterogeneous enhancement raise malignancy concern.
Above 4 cm in size
Surgery recommended regardless of CT characteristics — risk of ACC increases significantly above 4cm. At KIMS, all adrenal masses above 4cm are reviewed at MDT and offered robotic adrenalectomy.
Above 6 cm in size
High ACC risk — surgical resection is mandatory.
Growth of more than 1 cm on serial imaging
Suggests malignancy even if initial CT appeared benign — surgery recommended.
Hormonal evaluation — mandatory for all adrenal masses
1mg overnight dexamethasone suppression test (DST)
Screens for cortisol-secreting tumours (Cushing's syndrome or subclinical Cushing's). If morning cortisol after 1mg dexamethasone given at midnight is above 50 nmol/L, further evaluation is required.
24-hour urine catecholamines and metanephrines (or plasma metanephrines)
Screens for phaeochromocytoma. Must be performed before any adrenal surgery — operating on an unrecognised phaeochromocytoma without appropriate alpha-blockade can cause fatal hypertensive crisis intra-operatively.
Plasma aldosterone-to-renin ratio (ARR)
Screens for primary hyperaldosteronism (Conn's syndrome). Performed in hypertensive patients with an adrenal mass or unexplained hypokalaemia.
DHEAS and androgens
Elevated in adrenocortical carcinoma. Screens for virilising tumours.
Treatment — robotic adrenalectomy at KIMS
Surgical removal is indicated for: all phaeochromocytomas, all functioning adrenal masses (cortisol, aldosterone, or catecholamine secreting), masses above 4cm, masses with imaging characteristics suggesting malignancy, and masses that grow on surveillance imaging. At KIMS, laparoscopic or robotic adrenalectomy is performed by Dr. Likhiteswer Pallagani — a minimally invasive procedure through 3 to 4 small incisions, with hospital discharge in 1 to 2 nights and return to normal activity within 1 to 2 weeks. Open adrenalectomy is reserved for large ACC where en bloc resection with surrounding structures is required.
Book an Adrenal Mass Evaluation at KIMS
Frequently Asked Questions — Adrenal Mass
In most cases — no. Approximately 80 to 85% of adrenal masses found incidentally on CT are benign, non-functioning cortical adenomas with no hormonal activity and no malignancy risk. However, every adrenal mass requires two specific tests: hormonal screening (to exclude a functioning tumour) and CT characterisation (to assess the risk of malignancy based on HU attenuation and size). These tests are straightforward and can be completed within 1 to 2 weeks. A mass below 10 HU on non-contrast CT, below 4cm, with negative hormonal screening is almost certainly benign and requires only annual surveillance imaging for 2 to 3 years.
No. Small (below 4cm), non-functioning, imaging-benign adrenal masses are managed with surveillance — repeat CT or MRI at 6 to 12 months, then annually for 2 to 3 years. Surgery is indicated for masses above 4cm (regardless of hormonal status), all functioning masses (phaeochromocytoma, Cushing's, Conn's), masses with imaging features suggesting malignancy (poor washout, irregular margins, heterogeneous enhancement), and any mass that grows by more than 1cm on surveillance imaging.
Phaeochromocytoma — a catecholamine-secreting adrenal tumour — must be excluded before any adrenal operation. If a phaeochromocytoma is operated on without the patient being prepared with alpha-adrenergic blockade (phenoxybenzamine or doxazosin, started 10 to 14 days before surgery), manipulation of the tumour releases massive quantities of adrenaline and noradrenaline — causing severe, potentially fatal hypertensive crisis, arrhythmias, and cardiovascular collapse intra-operatively. This is an absolute surgical safety requirement. Plasma or urine metanephrine testing excludes phaeochromocytoma before any adrenal surgery is planned.
Adrenocortical carcinoma (ACC) is a rare but aggressive malignancy of the adrenal cortex, occurring in approximately 1 to 2% of adrenal masses. It is associated with larger size (typically above 4 to 6cm at presentation), irregular margins, heterogeneous enhancement, and poor CT washout. It may produce excess cortisol, androgens, or aldosterone. ACC is treated with complete surgical resection (open adrenalectomy for large lesions, robotic for selected smaller cases) combined with adjuvant mitotane therapy. At KIMS, all adrenal masses with features suggesting ACC are reviewed at the MDT tumour board before surgery is planned.
KIMS Secunderabad — Dr. Likhiteswer Pallagani (Vattikuti Foundation fellowship, 400+ robotic procedures, MDT tumour board), complete hormonal workup (1mg DST, plasma metanephrines, ARR), CT characterisation with HU measurement and washout calculation, robotic and laparoscopic adrenalectomy, alpha-blockade protocol for phaeochromocytoma surgery. Da Vinci Xi AND X. Call 040-4488-5000.