Adrenal cortical adenomas are benign tumors that stem from the cortex of the adrenal gland. These adenomas are frequently discovered as adrenal incidentalomas, adrenal tumors confirmed on imaging during a workup for unrelated causes. Nearly 85% of adrenal incidentalomas are benign and nonfunctional [1] [2]. Functioning adrenal cortical adenomas may cause hypertension, orthostatic hypotension, and tachycardia. A physical exam may reveal central obesity, hirsutism, striae, and gynecomastia. An ophthalmologic exam may reveal retinopathy secondary to chronic hypertension. Endocrine diseases resulting from functioning adrenal cortical adenomas reflect the excess production of adrenal gland hormones such as aldosterone (primary aldosteronism), cortisol (Cushing's syndrome), and sex hormones.

Primary aldosteronism is not characterized by a specific clinical presentation. These patients may have unprovoked hypokalemia and hypertension although potassium levels can be normal [3]. As a result of hypernatremia, hypokalemic alkalosis, and other related mechanisms, patients may develop fatigue, weakness, headaches, tetany, and paresthesias. Also, polyuria and polydipsia could result from hypokalemia-induced nephrogenic diabetes insipidus. Complications secondary to chronic hypertension include renal, cardiac, neurologic, and ophthalmologic manifestations.

Cushing's syndrome is characterized by weakness, bruising, weight gain, and depression. Affected individuals may also develop osteoporosis and metabolic syndrome [4].

Finally, androgen or estrogen-secreting tumors may cause virilization in females and feminization in males.

• Diastolic Hypertension

  RESULTS: Nineteen patients were cured of their hypertension postoperatively, whereas 13 patients had persistent diastolic hypertension. [ncbi.nlm.nih.gov]

• Leg Pain

  The authors report a primary spinal intramedullary adrenal cortical adenoma in a patient with spinal dysraphism presenting with bilateral leg pain and urinary frequency. [ncbi.nlm.nih.gov]

  The tumor, which was located at the L2 level, manifested itself clinically by a short history of bilateral leg pain. It was well encapsulated: therefore, total surgical removal was accomplished. [journals.lww.com]

• Hirsutism

  A physical exam may reveal central obesity, hirsutism, striae, and gynecomastia. An ophthalmologic exam may reveal retinopathy secondary to chronic hypertension. [symptoma.com]

  These androgen secreting tumours frequently present in women with increased facial hair growth (hirsutism), irregular periods and infertility sometimes with masculinization. It is a very rare cause of polycytic ovary syndrome. [ensat.org]

  Physical examination: truncal and centripetal obesity, thin extremities with muscle atrophy, plethoric moon face, echymoses and hirsutism. [endocrine-abstracts.org]

  Postoperatively, her hirsutism regressed, she rapidly went through puberty, and regular monthly menstruation started four months later. Finding the source of testosterone in a virilized patient can be difficult. [jamanetwork.com]

  Conn's syndrome: hypertension, proximal muscle weakness, headache, polyuria, tachycardia with/without palpitation, hypokalemia, hypocalcemia Hypercortisolism/Cushing's syndrome: central obesity, moon facies, plethora, striae, thin skin, easy bruising, hirsutism [pathologyoutlines.com]

• Recurrent Headache

  In 1995, she was referred to our clinic again because of recurrent headache and palpitation, and enlargement of the left adrenal tumor. [ncbi.nlm.nih.gov]

• Paresthesia

  As a result of hypernatremia, hypokalemic alkalosis, and other related mechanisms, patients may develop fatigue, weakness, headaches, tetany, and paresthesias. [symptoma.com]

All individuals suspected to have adrenal cortical adenoma, whether based on symptoms or an incidental finding on imaging, need a detailed assessment. The workup should include a personal and family history, a thorough physical exam, and appropriate studies.

In the evaluation of adrenal incidentalomas, it is very important to consider the possibility of pheochromocytoma [5]. To identify a pheochromocytoma, the first-line test is the measurement of plasma fractionated metanephrines and normetanephrines and/or 24-hour urine collection of metanephrines and catecholamines [6].

Primary aldosteronism is confirmed with the ratio of plasma aldosterone concentration to plasma renin activity [7]. Moreover, the diagnosis is likely when the aldosterone–to–renin ratio is above 30 and the plasma aldosterone level is elevated (>0.5 nmol/L) [8]. Also, an electrolyte panel should be obtained in these patients.

An important test in the diagnosis of Cushing's syndrome is an overnight dexamethasone suppression test [9]. Other considerations in these patients include screening for metabolic syndrome with a lipid panel and glucose tolerance test.

Patients with virilization or feminization should be tested for androgens and estrogens respectively.

On unenhanced computed tomography (CT) scan, adrenal cortical adenoma is characterized by a low attenuation which reflects the presence of an abundant intracytoplasmatic fat [10]. Also, CT and magnetic resonance imaging (MRI) are both effective in discriminating between benign and malignant masses. Additionally, positron-emission tomography (PET) with 18F-fluorodeoxyglucose (18F-FDG) demonstrates excellent sensitivity for confirming adrenal malignancy [11].

Fine-needle aspiration has limited value and is reserved for cases in which all other findings are inconclusive [12].

• Erythroblast

  The adrenal cortical adenoma centrally included well-demarcated adipose tissue admixed with scattered islands of myelopoietic elements: erythroblasts, myeloid cell series and lymphocytic cells, which was eventually recognized as myelolipoma. [ncbi.nlm.nih.gov]

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2. Nieman LK. Approach to the patient with an adrenal incidentaloma. J Clin Endocrinol Metab. 2010;95(9):4106-4113.
3. Cruz DN, Perazella MA. Hypertension and hypokalemia: unusual syndromes. Conn Med. 1997;61(2):67-75.
4. Chiodini I, Morelli V, Masserini B, et al. Bone mineral density, prevalence of vertebral fractures, and bone quality in patients with adrenal incidentalomas with and without subclinical hypercortisolism: an Italian multicenter study. J Clin Endocrinol Metab. 2009;94(9):3207-3214.
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9. Emral R, Uysal AR, Asik M, et al. Prevalence of subclinical Cushing's syndrome in 70 patients with adrenal incidentaloma: clinical, biochemical and surgical outcomes. Endocr J. 2003;50(4):399-408.
10. Szolar DH, Korobkin M, Reittner P, et al. Adrenocortical carcinomas and adrenal pheochromocytomas: mass and enhancement loss evaluation at delayed contrast-enhanced CT. Radiology. 2005;234(2):479-485.
11. Yun M, Kim W, Alnafisi N, et al. 18F-FDG PET in characterizing adrenal lesions detected on CT or MRI. J Nucl Med. 2001;42(12):1795-1799.
12. Mazzaglia PJ, Monchik JM. Limited value of adrenal biopsy in the evaluation of adrenal neoplasm: a decade of experience. Arch Surg. 2009;144(5):465-470.