When Lung Cancer Spreads to Adrenal Glands

If you've been told that your lung cancer (or another cancer) has spread to your adrenal glands (adrenal metastases) you may be feeling confused. Unlike the spread of cancer to other areas, such as the liver, spread to the adrenal glands isn't talked about as frequently. That said, adrenal metastases are very common with lung cancer. Where are the adrenal glands and what does it mean if your lung cancer spreads to this location?

Learn why metastases to the adrenal glands may have a better prognosis than other sites of metastases, especially when they occur on the same side of the body as a cancer.

The adrenal glands are small triangular shaped glands that are located on top of each kidney. These endocrine glands are responsible for secreting hormones, including "stress hormones" such as cortisol, epinephrine (adrenaline), and norepinephrine.  

Nearly any cancer can spread to the adrenal glands, but some tumors are more likely than others to metastasize to this region. In one study, the most common cancer responsible for adrenal metastases was the lung (35 percent) followed by stomach cancer (14 percent) esophageal cancer (12 percent) and liver/bile duct cancer (10 percent). Other common cancers that spread to this region include kidney cancer, melanoma, breast cancer, colon cancer, and lymphoma.

If lung cancer has spread to the adrenal glands, it is considered stage 4 non-small cell lung cancer (or extensive stage small cell lung cancer). In the past, there was little to do once lung cancer had metastasized. In recent years, however, it's been noted that for some people—especially those with an isolated adrenal metastasis—aggressive surgical treatment of the metastasis may result in long-term survival. As discussed further below, the prognosis for adrenal metastases from lung cancer may be better than the prognosis of other metastases—such as those to the liver, brain, and bones. 

Up to 40 percent of people with lung cancer will develop adrenal metastases at some time, and in 10 percent of people with non-small cell lung cancer, the disease spreads to both adrenal glands. These metastases are present in 2 to 3 percent of people at the time of diagnosis, and on rare occasions are the first sign of lung cancer.

Most of the time when cancer spreads to the adrenal glands there aren't any symptoms. In fact, in one study only 5 percent of people with adrenal metastases had symptoms. People are most often only aware of these metastases due to radiology studies such as a CT scan, MRI, or PET scan.

When symptoms are present, they may include:

• Back pain (in the mid-back region).
• Abdominal pain.
• Bleeding into the abdomen (hemorrhage).
• Adrenal insufficiency (Addison's disease): Symptoms of Addison's disease may include weakness, low blood pressure (hypotension), low blood sugar (hypoglycemia), a low sodium level in the blood (hyponatremia), and a high potassium level (hyperkalemia).

If you have a scan suspicious for adrenal metastases, you won't necessarily need any further evaluation, especially if you have metastases to other regions of your body. In some cases, your doctor may wish to be certain that a mass in your adrenal gland is due to metastatic cancer, and recommend a CT-guided biopsy.

The treatment recommended for adrenal metastases can vary depending on several factors. For all people supportive care is important. In people with symptoms such as hemorrhage, treatments such as surgery may be necessary to control symptoms. In some people, treatment with the goal of curing cancer may be a possibility.

Supportive Care: Whether or not you and your doctor decide upon further treatment of your cancer or your adrenal metastases, caring for your symptoms remains paramount. People with cancer deserve good pain management and control of other symptoms related to cancer.

Treatment of Symptoms: As noted above, adrenal metastases rarely cause symptoms. If a metastasis is bleeding (hemorrhaging) or is at high risk of bleeding, surgery to remove the tumor and adrenal gland (adrenalectomy) may be recommended. If the metastasis has resulted in adrenal insufficiency, treatment with steroids may be needed. If back pain or abdominal pain occurs, this should be treated.

Treatment of the Primary Tumor and Other Metastases: Treating stage 4 lung cancer may include chemotherapy, targeted therapies, immunotherapy, and/or radiation therapy. Some people also participate in clinical trials studying new drugs and procedures. The addition of targeted therapies and immunotherapy, have changed the face of advanced lung cancer for many people in recent years. When targetable mutations are present, targeted drugs can sometimes allow physicians to treat stage 4 lung cancer almost like a chronic disease. While resistance occurs to these drugs in time, in some cases second generation and now third generation drugs are available should this occur. Immunotherapy, when effective, has sometimes even resulted in a "durable response," holding lung cancer in check for a lengthy period of time. Since the first drug in this category was only approved in 2015, we have yet to know if the remissions we sometimes see will last, or what the long-term outcomes may be.

Treatment With a Curative Intent: For people with an isolated adrenal metastasis, treatment may potentially result in long-term survival. Options include:

• Surgery: Both open and laparoscopic adrenalectomy (removal of an adrenal gland) may be done with a curative intent for some people.
• SBRT: If surgery isn't possible, studies suggest that stereotactic body radiotherapy (SBRT) may be effective and well tolerated. SBRT involves using a high dose of radiation to a small area, and sometimes has results similar to surgery.
• Ablation: Image guided percutaneous ablation is yet another option. A 2018 study found that, although survival was poorer for those with non-small cell lung cancer who underwent the procedure than with some other cancers, image-guided percutaneous ablation of adrenal metastases may extend local progression-free survival as well as overall survival. In the study, the average overall survival (for all tumor types combined) at 1, 3, and 5 years was 82, 44, and 34 percent following the procedure.

Without treatment, the median survival following a diagnosis of adrenal metastases was only 3 months in one study. That said, and unlike metastases to other regions of the body, treatment of these metastases in selected people with non-small cell lung cancer has resulted in long-term survival. These survival statistics were also compiled before newer treatments such as immunotherapy, and many of the targeted therapies we now have, were approved for lung cancer.

Several small studies evaluating the treatment of adrenal metastases have been encouraging. For example, in one study of 37 patients, overall survival was 34 percent for those patients who had surgery, but 0 percent for those who did not have surgery. Another recent study found that long-term survival was possible in 25 percent of participants who were treated for adrenal metastases.

With small cell lung cancer, a study found that, unlike metastases to the liver, brain, bone, and pleural fluid, metastases to the adrenal gland were not an unfavorable prognostic sign.

Why Might Prognosis Be Better for Adrenal Metastases Than Other Metastases?

The answer to the question about why adrenal metastases have a better prognosis, may be in how cancer spreads in order to arrive at the adrenal glands. Cancer spreads in 3 primary ways. One is locally near the tumor. Another is through the lymphatics. And the third is through the bloodstream. When cancer cells enter the bloodstream they travel throughout the body. (Some researchers believe that lung cancer may also spread aerodynamically, or through the airways.)

In one study evaluating the effectiveness of adrenalectomy on survival, it was found that with "ipsilateral disease"—that is, the spread of cancer to the adrenal gland on the same side of the body as the lung cancer—the 5-year survival rate was 83 percent. In contrast, the 5-year survival rate for people with "contralateral metastases"—adrenal metastases on the opposite side of the body from the lung cancer, the 5-year survival rate with surgery was zero.

It's thought that when lung cancer spreads to the adrenal gland on the same side of the body, it reaches the adrenal gland by way of the lymphatic system. In contrast, when the adrenal gland on the opposite side of the body is affected, it likely travels via the bloodstream (hematogenous spread) to arrive at the adrenal glands and the outcome is not as good.

A Word From Verywell

The prognosis with metastatic (stage 4) lung cancer is not what we would wish. That said, of all sites of metastases, adrenal metastases often have a better prognosis (and as noted, the prognosis is even better if the involved adrenal gland is on the same side of the body as the lung cancer). In addition, the treatment options and survival rates for advanced lung cancer in general are slowly improving, especially when targeted therapies for genetic mutations or immunotherapy drugs can be used to treat the tumor.

If you've been diagnosed with stage 4 lung cancer and adrenal metastases, take time to learn about your cancer. Participating in the lung cancer community online is very helpful. Newer treatments are improving survival rates, but the treatment of lung cancer is changing so rapidly that is hard for anyone to stay on top of the latest findings. If you are wondering how to find people who are on the "cutting edge" of lung cancer research, using the hashtag #lcsm for lung cancer social media is priceless.

You may wish to consider a second opinion at one of the larger National Cancer Institute-designated cancer centers, where oncologists who specialize in lung cancer have access to the latest research and clinical trials available. Most importantly, take an active part in your care and be your own advocate. We are learning that self-advocating (or having a friend or loved one who can research you disease and advocate for you), not only reduces anxiety and helps you feel more in control of your disease, but may improve outcomes as well.