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Medical history and physical exam

If you have  signs or symptoms  that suggest adrenal cancer, the first step is usually for the doctor to take your complete medical history to find out more about them.

• Your doctor will want to know if anyone in your family has had adrenal cancer or any other type of cancer.
• Your doctor might also ask about your menstrual or sexual function and about any other symptoms you may be having.

A physical exam will give other information about possible signs of adrenal cancer or other health problems.

• Your doctor will thoroughly examine your abdomen for evidence of a tumor (or mass).
• You probably will have blood and urine tests to look for high levels of the hormones made by some adrenal tumors.
• If an adrenal tumor is suspected, you might have imaging tests to look for it. 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 would not recommend an initial biopsy, which is removing a sample of the tumor to look at it under the microscope to see if it is cancer. If the tumor looks suspicious on imaging tests, it will be removed if possible.   

Imaging tests

Computed tomography (CT)

Adrenal glands show up well on CT scans and  the location of the cancer can usually be confirmed. CT scans also can often help determine if the cancer has spread to lymph nodes and other organs. These findings can help doctors determine if the adrenal tumor is an adenoma or a carcinoma (cancer), by looking at the following:

• Size: Tumors larger than 4 cm (1.5 inches) suggest adrenal cancer.
• Shape: Irregularly shaped adrenal tumors suggest adrenal cancer.
• Density: Low density generally indicates the presence of fat, which is suggestive of an adenoma. Density is measured using Hounsfield units (HU) on CT scan. HU less than 10 is suggestive of an adenoma.  

Magnetic resonance imaging (MRI)

Like CT scans,  MRI scans  show detailed images of soft tissues in the body. While a CT scan is the most common form of imaging used for adrenal tumors, MRI is used in certain situations:

• To avoid exposure to radiation: MRI scans use radio waves and strong magnets instead of x-rays.
• To gather more information: MRI scans can better distinguish adrenal cancers from benign tumors.

To look for a tumor in the brain: In some people with higher-than-normal cortisol levels, an MRI of the brain may be done to examine the pituitary gland, which is a gland that lies under the front of the brain and makes hormones, including the adrenocorticotropic hormone (ACTH). Imaging of the pituitary gland can help doctors better understand if an ACTH-producing tumor is causing the symptoms.

Positron emission tomography (PET)

For a  PET  scan, you are injected with a slightly radioactive form of sugar, which collects mainly in cancer cells. A special camera then creates a picture of areas of radioactivity in the body. The picture is not detailed like a CT or MRI scan, but a PET scan can look for possible areas of cancer spread in all areas of the body at once.

Some machines do both a PET and CT scan at the same time (PET/CT scan). This lets the doctor see areas that "light up" on the PET scan in more detail.

PET scans can be helpful in deciding if an adrenal tumor is likely to be malignant (cancer), and if it has spread.

Other tests

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 procedure is called a  biopsy.

Since biopsy samples from adrenal adenomas (benign tumors) and carcinomas (cancer) can look alike under the microscope, a biopsy may not tell if an adrenal tumor is cancerous. A needle biopsy of an adrenal cancer also can spread tumor cells. For these reasons, a biopsy is generally not done before surgery if an adrenal tumor's size and features seen on imaging tests suggest cancer. Blood tests of hormone levels combined with imaging are more useful than biopsies in diagnosing adrenal cancer.

If the cancer looks like it 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 done in a patient with adrenal cancer when there are tumors (metastases) outside the adrenals and the doctor needs to know if they are from the adrenal cancer or are caused by some other cancer or disease. Tumors in the adrenal glands are sometimes biopsied when the patient is known to have a different type of cancer (like lung cancer) and knowing if it has spread to the adrenal glands would alter treatment.

Blood and urine tests for adrenal hormones

Blood and urine tests to measure levels of adrenal hormones are important in understanding if a patient has a functional (hormone-secreting) adrenal tumor. Blood and urine tests are as important as imaging tests in diagnosing adrenal cancer. Doctors might choose which tests to do based on the patient's symptoms. But often doctors will check hormone levels even when there are no symptoms they might be high. This is because symptoms of abnormal hormone levels can be very subtle, and blood tests might be able to detect abnormal hormone levels even before symptoms occur.

Tests for high cortisol levels

The levels of cortisol are measured in the urine, saliva, and blood. If an adrenal tumor is making cortisol, these levels will be abnormally high.

For urine tests, you may be asked to collect all your urine for 24 hours. This is called a 24-hour urinary free cortisol test.

Saliva may also be collected to measure cortisol levels.

For blood tests, you may be asked to take a drug called dexamethasone the night before, followed by a fasting blood draw to check the cortisol level the next morning. This is called an overnight dexamethasone suppression test and is used to help diagnose Cushing syndrome. Other blood work may include a fasting glucose level and corticotropin (ACTH) test.

Tests for high aldosterone levels

The level of aldosterone will be high if the tumor is making aldosterone. High aldosterone can lead to low blood levels of potassium and renin (a hormone made by the kidneys).

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.