Malignant Adrenal Mass - Differential Diagnosis Algorithm

Suggestive of Malignancy: Inhomogenous Density, Delay in CT Contrast Washout (<50% in 10 minutes), Irregular Shape, Diameter >4cm, Calcification, >20 Hounsfeld Units on CT, Vascularity of Mass, Hypointense to Liver on TI Weighted MRI — DO NOT Biopsy

Androgen Excess - Virilization/ Hirsutism

 • High DHEAS - Androgen Releasing Carcinoma (e.g. Adrenocortical Carcinoma)

 • Normal DHEAS - Other Source (e.g. Polycystic Ovarian Syndrome, Congenital Adrenal Hyperplasia)

Estrogen Excess - Feminization, Early Puberty, Heavy Menses

 • Estrogen Releasing Carcinoma (High Plasma E2 + Clinical Picture)

Glucocorticoid Excess - Cushingoid Features

 • Glucocorticoid Releasing Carcinoma (Positive Dexamethasone Suppression Test)

Aldosterone Excess Hypertension +/- Hypokalemia/Alkalosis

 • Aldosterone Releasing Carcinoma (High Aldosterone: Renin Ratio)

Positive 24-Hour Metanephrines + Nor-Metanephrines

 • Pheochromocytoma (Paroxysmal Hypertension, Headache, Diaphoresis, Palpitations, Anxiety) 

Silent/Non-Functioning Mass

 • Lymphoma Metastases (Often Bilateral) Adrenal Carcinoma



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