Metastasis to the adrenal glands: An update

Table 5 Practical comparison of treatment strategies for adrenal metastases

Strategy	Ideal case	Advantages	Limitations	Safety considerations	Evidence
Adrenalectomy	Isolated adrenal metastasis or oligometastatic disease where complete local control is feasible; surgically fit patient	Definitive resection, tissue diagnosis, local control, potential durable survival in selected patients	Requires operative fitness; benefit is highly selection-sensitive; less suitable for uncontrolled polymetastatic disease	Bleeding, adjacent-organ injury, conversion, pancreatic/splenic injury on the left, inferior vena cava/right adrenal vein risk on the right	Mostly retrospective cohorts and comparative series; no adrenal-specific randomized trial[21-26]
Percutaneous ablation	Small adrenal lesions; non-operative candidates; patients needing lower-morbidity local treatment	Minimally invasive, repeatable, short hospital stay, useful when surgery is high-risk	Local control is size-sensitive; limited evidence for large/invasive lesions; proximity to bowel, pancreas, kidney, diaphragm, or major vessels may limit feasibility	Pain, bleeding, thermal injury, hypertensive crisis, adrenal insufficiency, incomplete ablation/local progression	Retrospective series; heterogeneous modalities and lesion-size thresholds[27-32]
Stereotactic body radiotherapy	Oligometastatic or oligoprogressive disease; non-surgical candidates; anatomically difficult lesions; outpatient local therapy	Non-invasive, high local control in selected series, can preserve systemic therapy continuity	Dose/fractionation varies; organ-at-risk constraints may limit dose; response assessment may be delayed	Nausea, fatigue, abdominal pain, gastritis/enteritis, ulceration/bleeding, renal dose exposure, adrenal insufficiency especially after bilateral treatment	Systematic review plus mostly retrospective cohorts; limited prospective data[36-45]
Conventional radiotherapy	Symptomatic disease, pain, bleeding risk, palliation when ablative treatment is not appropriate	Widely available; useful for symptom relief	Less ablative than stereotactic body radiotherapy; limited durable-control data	Gastrointestinal toxicity, fatigue, incomplete symptom response	Older and mostly palliative evidence[33,34]
Systemic therapy/best supportive care	Polymetastatic or rapidly progressive disease; adrenal lesion not dominant driver; poor local therapy candidate	Treats whole-body disease; aligns with primary tumor biology and goals of care	May not rapidly control symptomatic or threatening adrenal lesion	Regimen-specific toxicity; adrenal insufficiency if bilateral adrenal involvement progresses	Primary tumor-specific evidence; adrenal-specific comparative data limited[54-58]