2
Adrenal incidentaloma

https://doi.org/10.1016/j.beem.2011.12.006Get rights and content

Adrenal incidentaloma is a common clinical problem and its prevalence, in radiological studies, comes close to that of autoptic data as a result of imaging technological advances. The diagnostic challenge is to distinguish the majority of benign lesions from other masses, either malignant or hormone secreting, which require further therapy. The imaging evaluation (unenhanced CT and MRI) can differentiate malignant to benign lesions because the benign lesions have high lipid content. All patients should be tested for hypercortisolism and pheochromocytoma whereas aldosteronism should be tested in hypertensive patients only. The optimal diagnostic management for adrenal incidentaloma is still controversial, and the endocrinologist must devise a cost-effective approach taking into account the extensive endocrine work-up and imaging investigations that may be necessary. A tailored strategy may be based on the selection of patients at increased risk who require a careful and extensive follow-up among the vast majority of patients who require a simplified follow-up.

Section snippets

Definition, prevalence and etiology

An adrenal incidentaloma is a previously unsuspected adrenal mass that is discovered on an imaging study performed for an unrelated reason. Although, in most cases, these masses are nonfunctional adrenocortical adenomas requiring no further treatment, they still represent an important clinical concern because of the risk of malignancy or hormonal hyperfunction. Therefore, the term adrenal incidentaloma is an “umbrella“ definition and is not a diagnosis.

The prevalence of adrenal incidentalomas

Imaging evaluation

The imaging evaluation (CT and MRI) is a key tool to differentiate malignant from benign lesions. In contrast to malignant lesions, the majority of adrenocortical adenomas contain significant intracellular lipids. An inverse linear relationship exists between lipid concentration and attenuation on unenhanced CT images. For this reason, the mean attenuation value of adenomas is significantly lower than that of the nonadenomas at CT densitometry. In clinical practice, a signal intensity lower

Endocrine evaluation

Most adrenal incidentalomas are nonfunctional adenoma, however, an endocrine evaluation can reveal a significant number of cases of clinically unsuspected adrenal functional tumors.

All subjects with adrenal incidentaloma should be screened for pheochromocytoma and for hypercortisolism. Most authors suggest not to perform endocrine screening in patients with adrenal masses whose imaging characteristics are typical for myelolipoma or adrenal cysts*3, 23 but in some cases even these masses showed

Management and natural history

After the discovery of an adrenal incidentaloma several questions should be addressed: 1) Is the mass malignant?; 2) Is the tumor hormonally active even in the absence of a clinical phenotype?; 3) What are the indications for surgery?; 4) Can a mass initially diagnosed as ‘benign’ become ‘malignant?‘; 5) Is it possible that a biochemically inactive mass could become hyperfunctioning?; 6) What is the morbidity and mortality of subclinical hypercortisolism ?; 7) What is the morbidity and

Disclosure statement

The authors have nothing to disclose.

References (88)

  • C. Reinhard et al.

    Adrenocortical nodules in post-mortem series. Development, functional significance, and differentiation from adenomas

    General and Diagnostic Pathology

    (1996)
  • S. Bovio et al.

    Prevalence of adrenal incidentaloma in a contemporary computerized tomography series

    Journal of Endocrinological Investigation

    (2006)
  • D.C. Aron

    The adrenal incidentaloma: disease of modern technology and public health problem

    Reviews in Endocrine & Metabolic Disorders

    (2001)
  • G.T. Griffing

    A-I-D-S: the new endocrine epidemic

    Journal of Clinical Endocrinology and Metabolism

    (1994)
  • F. Mantero et al.

    A survey on adrenal incidentaloma in Italy. Study Group on Adrenal Tumors of the Italian Society of Endocrinology

    Journal of Clinical Endocrinology and Metabolism

    (2000)
  • T.J. Cawood et al.

    Recommended evaluation of adrenal incidentalomas is costly, has high false-positive rates and confers a risk of fatal cancer that is similar to the risk of the adrenal lesion becoming malignant; time for a rethink?

    European Journal of Endocrinology

    (2009)
  • M. Fassnacht et al.

    Adrenocortical carcinoma: a clinician’s update

    Nature Reviews Endocrinology

    (2011)
  • W.F. Young

    The incidentally discovered adrenal mass

    New England Journal of Medicine

    (2007)
  • M.A. Blake et al.

    Adrenal imaging

    AJR American Journal of Roentgenology

    (2010)
  • M. Fassnacht et al.

    Adrenal tumors: how to establish malignancy?

    Journal of Endocrinological Investigation

    (2004)
  • A. Klibanski et al.

    Case records of the Massachusetts General Hospital. Case 36-2006. A 35-year-old pregnant woman with new hypertension

    New England Journal of Medicine

    (2006)
  • M.A. Blake et al.

    Pheochromocytoma: an imaging chameleon

    Radiographics

    (2004)
  • J.J. Erasmus et al.

    Evaluation of adrenal masses in patients with bronchogenic carcinoma using 18F-fluorodeoxyglucose positron emission tomography

    American Journal of Roentgenology

    (1997)
  • S. Maurea et al.

    Imaging of adrenal tumors using FDG-PET: comparison of benign and malignant lesions

    American Journal of Roentgenology

    (1999)
  • M. Yun et al.

    18F-FDG PET in characterizing adrenal lesions detected on CT or MRI

    Journal of Nuclear Medicine

    (2001)
  • F. Tenenbaum et al.

    18F-fluorodeoxyglucose positron emission tomography as a diagnostic tool for malignancy of adrenocortical tumours? Preliminary results in 13 consecutive patients

    European Journal of Endocrinology

    (2004)
  • L. Groussin et al.

    18F-Fluorodeoxyglucose positron emission tomography for the diagnosis of adrenocortical tumors: a prospective study in 77 operated patients

    Journal of Clinical Endocrinology and Metabolism

    (2009)
  • M. Boronat et al.

    Subclinical Cushing’s syndrome due to adrenal myelolipoma

    Archives of Pathology & Laboratory Medicine

    (1997)
  • C. Lamas et al.

    Myelolipomatous adrenal masses causing Cushing’s syndrome

    Experimental and Clinical Endocrinology & Diabetes

    (2009)
  • H. Hisamatsu et al.

    Combined adrenal adenoma and myelolipoma in a patient with Cushing’s syndrome: case report and review of the literature

    International Journal of Urology

    (2004)
  • L.K. Nieman

    Approach to the patient with an adrenal incidentaloma

    Journal of Clinical Endocrinology and Metabolism

    (2010)
  • H.Y. Kim et al.

    Clinical study of adrenal incidentaloma in Korea

    Korean Journal of Internal Medicine

    (2005)
  • M. Mannelli et al.

    Pheochromocytoma in Italy: a multicentric retrospective study

    European Journal of Endocrinology

    (1999)
  • R. Kopetschke et al.

    Frequent incidental discovery of phaeochromocytoma: data from a German cohort of 201 phaeochromocytoma

    European Journal of Endocrinology

    (2009)
  • L. Amar et al.

    Year of diagnosis, features at presentation, and risk of recurrence in patients with pheochromocytoma or secreting paraganglioma

    Journal of Clinical Endocrinology and Metabolism

    (2005)
  • K. Pacak et al.

    Phaeochromocytoma: recommendations for clinical practice from the First International Symposium. October 2005

    Nature Clinical Practice Endocrinology & Metabolism

    (2007)
  • E. Grouzmann et al.

    Diagnostic accuracy of free and total metanephrines in plasma and fractionated metanephrines in urine of patients with pheochromocytoma

    European Journal of Endocrinology

    (2010)
  • A.M. Sawka et al.

    A comparison of biochemical tests for pheochromocytoma: measurement of fractionated plasma metanephrines compared to the combination of 24-hour urinary metanephrines and catecholamines

    Journal of Clinical Endocrinology and Metabolism

    (2003)
  • G. Eisenhofer et al.

    Biochemical diagnosis of pheochromocytoma: how to distinguish true- from false-positive test results

    Journal of Clinical Endocrinology and Metabolism

    (2003)
  • J.W. Funder et al.

    Case detection, diagnosis, and treatment of patients with primary aldosteronism: an Endocrine Society clinical practice guideline

    Journal of Clinical Endocrinology and Metabolism

    (2008)
  • G.P. Piaditis et al.

    High prevalence of autonomous cortisol and aldosterone secretion from adrenal adenomas

    Clinical Endocrinology

    (2009)
  • V. Médeau et al.

    Clinical and biochemical characteristics of normotensive patients with primary aldosteronism: a comparison with hypertensive cases

    Clinical Endocrinology

    (2008)
  • W.F. Young

    Primary aldosteronism: renaissance of a syndrome

    Clinical Endocrinology

    (2007)
  • T. Nishikawa et al.

    Should primary aldosteronism be diagnosed among normotensive subjects during general health check-up and/or at general outpatient clinics?

    Hypertension Research

    (2011)

    • Cited by (98)

    • Factors predicting prolonged glucocorticoid therapy in patients with adrenal insufficiency after laparoscopic adrenalectomy

      2022, Annals of Medicine and Surgery

    • Management of Incidentalomas

      2021, Surgical Clinics of North America
      Citation Excerpt :

      In addition to size, CT characteristics of intracellular lipid content and vascular enhancement patterns can be used to differentiate benign adenoma from malignancy; 70% of adrenal adenomas contain significant intracellular lipid with densitometry of less than 10 Hounsfield units attenuation and may allow for differentiation from malignant lesions with a sensitivity of 71% and a specificity of 98%.36–39 A lesion displaying low attenuation densitometry on nonenhanced CT with other characteristics, including homogeneity and smooth borders, is more likely to be a benign adenoma.40 Up to 30% of adenomas do not have low attenuation by nonenhanced CT, making them indistinguishable from malignant lesions based on Hounsfield units.41,42

    • A Gigantic Uterine Leiomyoma and Big Bilateral Adrenal Myelolipomas as a Result of Untreated Congenital Adrenal Hyperplasia

      2021, AACE Clinical Case Reports

    • Laparoscopic surgery for adrenocortical carcinoma: Estimating the risk of margin-positive resection

      2024, Journal of Surgical Oncology

    • Giant Bilateral Adrenal Myelolipomas in a Non-Compliant Patient with Congenital Adrenal Hyperplasia

      2024, American Journal of Case Reports

    • Clinical presentation and diagnostic evaluation of pheochromocytoma: case series and literature review

      2023, Clinical and Experimental Hypertension
    View all citing articles on Scopus
    View full text
    Copyright © 2011 Elsevier Ltd. All rights reserved.