Malignant adrenal neoplasm masquerading as worrisome adrenal hemorrhage

Adrenal hemorrhage (AH) associated with adrenal neoplasm is rare. This study assesses the clinical and pathological impact of AH in the setting of malignant adrenal neoplasm to establish management strategies.

Patients admitted over a 25-year period with a diagnosis of AH and malignant adrenal neoplasm were retrospectively reviewed.

Malignant adrenal neoplasms were reported in 14 of 217 patients (6.4%) presenting with AH. Of these, 4 were women. Mean age was 56 years. The most common presenting symptom was abdominal pain (n = 6), followed by altered mental status and shock (2) and hypercortisolism (1). Five patients were asymptomatic. In 10 patients the adrenal tumor was metastatic. Four patients had adrenocortical carcinoma (ACC). All primary adrenal tumors were unilateral. Risk factors for AH were identified in 5 patients (anticoagulation, 3; trauma, 1; and recent surgery, 1). Computed tomography (n = 12) demonstrated adrenal masses ranging in size from 6.8 to 11.0 cm (mean, 9 cm). Nine patients were managed by surgical resection (adrenalectomy, 4; radical nephrectomy, 2; adrenalectomy/splenectomy, 1; adrenalectomy/bowel resection, 1; and laparotomy and packing, 1) Actual survival time ranged from 9 days to 7.8 years (median 329 days).

Most patients with AH in the setting of malignant adrenal neoplasm had metastatic tumors to the adrenal glands. These patients do not typically present in hemorrhagic shock, allowing for adequate preoperative evaluation for function and assessment for primary tumors. Long-term survival of these patients is rare.