If there is a large adrenal tumour with no evidence of metastases or local spread confirmation of malignancy can be difficult even when the tumour has been removed. The inability of adrenocorticocarcinomas to synthesise endpoint steroids results in high levels of steroid precursors such as serum DHEAS making high levels of these steroid precursors an indicator of malignancy. Important stages of diagnosis are blood and urine tests to indicate the presence of excess amounts of any adrenal hormones that may be being produced by the tumour. Imaging studies using abdominal CT and MRI scans provide useful data on the size of the tumour and whether it may have spread to other organs. Of special importance here is the kidney, directly attached to the adrenal gland, which will be one of the first organs to be invaded.
Ultrasound can be used and detects carcinomas in 80-90% of cases but does not provide as much information to the surgeon as CT.
On CT the adrenocortical carcinoma is typically large (greater than 5 cms on diameter)is irregular with hetreogenous density due to necrosis ,haemorrhage and calcification. Recent studies with PET scans appear to be suggest a usefullness in separating the benign from malignant lesion.
Often a tumour will be considered malignant purely because of its size. In 1984 Weiss devised a scoring system to distinguish benign from malignant lesions . (Weiss LM Comparative histiologic study of 43 metastasizing adrenocortical tumours Am J Surg Path 1984 8 163-9) . Some 25 years later this scoring system is still the most useful to separate the massive benigh cortical adenoma from the malignant cortical lesion.
Angiography (imaging studies where a dye is injected into the veins and X-rays taken to visualise the blood supply to the tumour) is also important for planning surgery.