Daily Checkup: Adrenal nodules and cancer

THE SPECIALIST: Dr. William Inabnet

A professor of surgery at Mount Sinai, Dr. William Inabnet is an endocrine and metabolic surgeon who who has been in the field for 15 years. Through the Adrenal Center, he oversees the care of more than 400 patients with adrenal nodules a year.

WHO’S AT RISK

Whether rooting for your favorite team or simply running late for a meeting, adrenaline is part of daily life for most Americans — but that doesn’t mean we spend much time thinking about where it comes from.

“Located above the kidneys, the adrenal glands produce a series of hormones that influence blood pressure control, electrolyte balance and stress response, including adrenaline — functions essential for life,” says Inabnet. “When nodules form on the adrenal glands, most of them require no treatment — but every nodule warrants a workup to rule out something more serious, including adrenal cancer.”

Adrenal nodules aren’t exactly a household word, but they are extremely common. “Thanks to CT scans, we now know that 5%-8% of the population harbor adrenal nodules,” says Inabnet. “There are two important categories of nodules: functioning nodules are making excess hormones, while nonfunctioning nodules are not.”

Although few adrenal nodules are actually cancerous, it’s essential to catch and treat adrenal cancer early, because it is highly aggressive.

The root cause of adrenal nodules remains largely unknown. “Certain familial conditions can predispose you to nodules, but that’s the only risk factor we’ve identified as yet,” says Inabnet. “Adrenal nodules affect men and women of all different ages. They can develop in anyone at anytime.”

SIGNS AND SYMPTOMS

While many nodules are asymptomatic, others manifest themselves through a slew of diverse warning signs.

“The excess hormones produced by functioning nodules can cause symptoms including poorly controlled hypertension, rapid-onset diabetes, weight gain, easy bruising, depression and anxiety,” says Inabnet. “Other patients experience panic attacks and muscle weakness.”

Even asymptomatic nodules should receive a thorough workup, because some of them do require treatment.

Many nodules are diagnosed when patients are receiving a CT scan or MRI for an unrelated problem. “A common scenario is that a patient gets a chest X-ray, or a lumbar evaluation for back pain, and the imaging picks up the nodule,” says Inabnet. “For all patients, a close review of the CT scan or MRI is essential for picking up adrenal nodules and confirming that diagnosis.”

TRADITIONAL TREATMENT

Upon being diagnosed with adrenal nodules, patients should receive a comprehensive workup to determine what kind of nodule it is and whether it requires treatment.

“All patients should be referred to an adrenal specialist and ideally an adrenal center, where you can see all your specialists in one location,” says Inabnet. “First, we use the CT or MRI imaging to look at the features of the nodule — the bigger it is, the greater the chance of cancer. Only a small percentage of adrenal nodules are cancerous.”

The second step is a hormonal evaluation. “The key is to determine whether the nodule is functioning — producing excess hormone — or nonfunctioning,” says Inabnet. “If the nodule is functioning, the treatment options depend on what hormone is being produced. If the nodule is nonfunctioning, active surveillance is often sufficient.”

Medication and surgery are the two primary treatment options. “If the nodule is producing excess cortisol — which is called Cushing’s syndrome — some patients require surgery while others may not,” says Inabnet. “Patients with subclinical Cushing’s — very mild cases — can actually be treated with the morning after pill, which turns off the adrenal gland.” There are also good medications to block the production of excess aldosterone.

Because one functioning adrenal glad is enough for living a healthy life, adrenal nodule surgery removes both the problematic mass and the rest of the gland.

“Most of these surgeries can be done laparoscopically, or minimally invasively,” says Inabnet. “But if there is any suspicion of cancer, we do an open surgery because it’s easier to avoid violating the capsule of the adrenal gland, and it’s our one chance to save the patient.”

Whether open or laparoscopic, the surgery is performed under general anesthesia, and most operations can be done in 1-2 hours, depending on the size and pathology of the nodule.

Most patients have a quick recovery period. “For patients who’ve had laparoscopic surgery, it’s usually just a one-night hospital stay,” says Inabnet. “Some patients’ metabolism takes a little longer to recover, but most patients find themselves feeling much better soon after surgery than they did before.”

RESEARCH BREAKTHROUGHS

Promising work is being done to get to the bottom of what causes adrenal nodules and tumors in the first place.

“With the genetic sequencing of various cancers, we’re starting to unravel why these cancers occur, and there are new targeted therapies being used under protocol,” says Inabnet. “We are also starting an adrenal cortical cancer consortium to study these very rare cancers by combining data sets and sharing tissue specimens, which should allow us to arrive at better treatments.”

QUESTIONS FOR YOUR DOCTOR

Any patient diagnosed with an adrenal nodule should be direct about asking the doctor, “How many patients do you treat for adrenal problems a year?” If your nodule does require surgery, the key question is, “How will the surgery be performed — as an open or laparoscopic surgery?”

While choosing the best course of treatment can be complicated — and is best done in consultation with a team of experts — intervention can transform your quality of life. “With proper treatment, most patients experience a dramatic improvement to their health,” says Inabnet. “Most patients simply feel much better after they receive treatment.”

WHAT YOU CAN DO

Get informed. Reliable places to start your online search are the American Society of Clinical Endocrinologists’ patient portal (www.aace.com/patient-portal) and the Mount Sinai Adrenal Center (adrenalcenter.info).

Don’t ignore the symptoms. If you are suffering from severe hypertension that isn’t responding to medical therapy — especially if you are also experiencing diabetes and weight gain — make an appointment to consult an endocrinologist.

See an expert. If you are diagnosed with an adrenal nodule, see an endocrinologist or an endocrine surgeon. And if your nodule requires treatment, look for a program that has interdisciplinary care.