Management Of Adrenal Incidentalomas Research Articles

Impact of adrenalectomy on hypertension in patients with nonfunctional adrenal tumors: a retrospective study.

To investigate the impact of adrenalectomy on hypertension in patients with nonfunctional adrenal tumors. Between January 2020 and October 2022, patients with adrenal lesions were retrospectively screened for nonfunctional adrenal tumors at the Zhongnan Hospital of Wuhan University. All patients underwent detailed endocrinological examination and computed tomography to characterize the lesions. One year after discharge, follow-up blood pressure (BP) was assessed and compared to the blood pressure on admission. Univariate analysis and multivariate regression analysis were performed to determine factors predicting favorable hypertension outcomes after adrenalectomy. A total of 309 patients were found to be eligible, including 123 who underwent adrenalectomy. Patients who underwent adrenalectomy were stratified into two groups: (Bancos I (2022) Adrenal Incidentalomas: Insights Into Prevalence. Ann Intern Med 175:1481-1482. https://doi.org/10.7326/M22-2600 ) those with improved hypertension (n = 71), and (Fassnacht M, Tsagarakis S, Terzolo M, Tabarin A, Sahdev A, Newell-Price J et al. (2023) European Society of Endocrinology clinical practice guidelines on the management of adrenal incidentalomas, in collaboration with the European Network for the Study of Adrenal Tumors. Eur J Endocrinol 189:G1-42. https://doi.org/10.1093/ejendo/lvad066 ) those without improved hypertension (n = 52). In contrast, the blood pressure levels of conservatively treated patients remained relatively stable 1 year after discharge. Univariate analysis and multivariate regression analysis showed that body mass index (BMI) and duration of hypertension were significantly different between the hypertension improvement group and the non-improvement group (p < 0.05). Adrenalectomy has been shown to be effective in improving hypertension in certain patients with nonfunctional adrenal tumors. BMI and duration of hypertension were independent factors associated with favorable hypertension outcomes after adrenalectomy.

Management of adrenal incidentalomas: a single-centre experience

Management of adrenal incidentalomas: a single-centre experience

O-04 A diagnostic riddle of an adrenal incidentaloma

Abstract Clinical case A 78-year-old male underwent preoperative CT as transcatheter aortic valve implantation was planned. In addition to a 6 cm incidental mass in the right adrenal, it also revealed unspecific pulmonary nodules. The patient was referred to the Endocrine unit. Non-contrast adrenal CT demonstrated a heterogenous 6 cm tumor, &amp;lt; 10 HU. The patient had a history of psoriasis, type 2 diabetes mellitus, hypertension, chronic kidney disease, atrial fibrillation, peripheral artery disease, aortic stenosis and coronary artery disease. Clinical examination revealed no signs of Cushing's syndrome. First, normal blood metanephrine/normetanephrine concentrations confirmed that pheochromocytoma was ruled out. The possibility of a metastatic tumor mass was investigated by tumor biopsy, histopathology was compatible with an adrenocortical neoplasm, Ki67 2%. Further laboratory work-up is given in Table 1. How should the laboratory findings be interpreted? Primary aldosteronism was ruled out. Cortisol was not suppressed on 1mg DST, in contrast to perfectly normal 24h urinary free cortisol. Late night salivary cortisol (LNSC) was markedly increased, 1210 nmol/l and low ACTH concentration further suggested true hypercortisolism. Does the patient suffer from hypercortisolism? The patient had no clinical signs of Cushing syndrome, albeit cardiometabolic diseases. False positive DST and LNSC results were suspected. Indeed, the patient was using 1% hydrocortisone lip lotion. On repeat screening after discontinuation of hydrocortisone, LNSC was 3.8 nmol/l, and DST remained positive (258nmol). The patient was diagnosed with autonomous cortisol excess (MACS) (1). Should the patient undergo surgery for the right adrenal mass? MACS in combination with relevant co-morbidities and large tumor size indicated surgery (1), which the patient consented to. After surgery, cortisol concentrations remained suppressed which prompted hydrocortisone replacement therapy. Final pathology review classified the tumor as an adenoma, Weiss Score 0/9 and Ki-67 2%. Conclusion False positive cortisol screening tests are common and must be ruled out before surgery. For DST, common explanations are exogenous glucocorticoid use, drugs that accelerate dexamethasone metabolism and estrogen induced increase in CBG. The most common pitfalls for LNSC are deranged circadian rhythm and exogenous hydrocortisone. Reference (1). Fassnacht el al. European Society of Endocrinology clinical practice guidelines on the management of adrenal incidentalomas. European Journal of Endocrinology,2023; 189(1): G1–G42.Table 1

Diagnosis and management of adrenal incidentaloma: use of clinical judgment and evidence in dialog with the patient

AbstractThe prevalence of adrenal incidentaloma (AI) in imaging studies, including those of the adrenal glands, is estimated to be 1–5%. Essential factors for the proper management of AI include a correct diagnosis, adequate surgical skills, appropriate perioperative management, and sound dialogue with the patient. Aside from the possibility of overdiagnosis, patients with apparent signs or symptoms attributable to adrenal hormone excess have reasonable indications for surgery. At the same time, milder patients may be candidates for active surveillance without intervention. Even individuals with nonfunctioning AI may benefit from surgery if imaging studies depict the tumor as suggestive of malignancy. However, a differential diagnosis of AI may not be easy for surgeons with little experience in seeing such patients.Furthermore, a patient without a correct diagnosis may miss the window of opportunity for a cure or incur a greater risk of developing complications, such as adrenal insufficiency or cardiovascular events during or after surgery, due to inadequate management. The clinical practice guidelines for AI from around the world may be helpful for shared decision-making; however, Japan lacks established guidelines. In this review article, we propose practical guidelines relevant to management by summarizing the evidence for five key questions that are often asked in dialog with patients with AI.

The investigation and management of adrenal incidentalomas at guy's and St Thomas's NHS foundation trust

The investigation and management of adrenal incidentalomas at guy's and St Thomas's NHS foundation trust

European Society of Endocrinology Clinical Practice Guidelines on the management of adrenal incidentalomas, in collaboration with the European Network for the Study of Adrenal Tumors.

Adrenal incidentalomas are adrenal masses detected on imaging performed for reasons other than suspected adrenal disease. In most cases, adrenal incidentalomas are non-functioning adrenocortical adenomas, but may also require therapeutic intervention including that for adrenocortical carcinoma, pheochromocytoma, hormone-producing adenoma or metastases. Here, we provide a revision of the first international, interdisciplinary guidelines on incidentalomas. We followed the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system and updated systematic reviews on four predefined clinical questions crucial for the management of incidentalomas: A) How to assess risk of malignancy? ; B) How to define and manage mild autonomous cortisol secretion? ; C) Who should have surgical treatment and how should it be performed? ; D) What follow-up is indicated if the adrenal incidentaloma is not surgically removed? Selected Recommendations: 1) Each adrenal mass requires dedicated adrenal imaging. Recent advances now allow discrimination between risk categories: Homogeneous lesions with HU ≤ 10 on unenhanced CT are benign and do not require any additional imaging independent of size. All other patients should be discussed in a multidisciplinary expert meeting, but only lesions >4 cm that are inhomogeneous or have HU >20 have sufficiently high risk of malignancy that surgery will be the usual management of choice. 2) Every patient needs a thorough clinical and endocrine work-up to exclude hormone excess including the measurement of plasma or urinary metanephrines and a 1-mg overnight dexamethasone suppression test (applying a cutoff value of serum cortisol ≤50 nmol/l (≤1.8 µg/dl)). Recent studies have provided evidence that most patients without clinical signs of overt Cushing's syndrome but serum cortisol levels post dexamethasone >50 nmol/l (>1.8 µg/dl) harbor increased risk of morbidity and mortality. For this condition, we propose the term 'mild autonomous cortisol secretion' (MACS). 3) All patients with MACS should be screened for potential cortisol-related comorbidities that are potentially attributably to cortisol (e.g. hypertension and type 2 diabetes mellitus), to ensure these are appropriately treated. 4) In patients with MACS who also have relevant comorbidities surgical treatment should be considered in an individualized approach. 5) The appropriateness of surgical intervention should be guided by the likelihood of malignancy, the presence and degree of hormone excess, age, general health and patient preference. We provide guidance on which surgical approach should be considered for adrenal masses with radiological findings suspicious of malignancy. 6) Surgery is not usually indicated in patients with an asymptomatic, non-functioning unilateral adrenal mass and obvious benign features on imaging studies. Furthermore, we offer recommendations for the follow-up of non-operated patients, management of patients with bilateral incidentalomas, for patients with extra-adrenal malignancy and adrenal masses, and for young and elderly patients with adrenal incidentalomas. Finally, we suggest ten important research questions for the future.

Prevalence, Diagnosis and Management of Adrenal Incidentalomas

Adrenal incidentalomas (AIs) are defined as adrenal masses incidentally discovered on imaging studies performed for unrelated reasons. AIs have become a common finding in clinical practice, particularly with the widespread application of high-resolution imaging techniques. While most AIs are nonfunctioning and benign, some cases can represent a clinical concern due to the risk of malignancy or hormone hyperfunction. The prevalence of AIs varies depending on the source of data and patient selection. The diagnosis of AIs relies on a combination of radiological, biochemical, and clinical evaluation to determine the functional status of the tumor and the potential for malignancy. The management of AIs remains a subject of controversy, with guidelines providing conflicting recommendations on the indications for surgical intervention and follow-up. Most AIs do not require surgical intervention, but appropriate follow-up is essential to detect any potential growth or functional changes. In cases where surgery is indicated, laparoscopic adrenalectomy is the gold standard, with open adrenalectomy reserved for masses highly suspicious for adrenal cortical carcinoma. A multidisciplinary approach involving endocrinologists, radiologists, and surgeons is crucial for optimal management of AIs.

ODP016 A case of adrenal incidentaloma in a patient with latent tuberculosis

Abstract An adrenal incidentaloma can be either a nonfunctioning adrenocortical adenoma or may cause disease, such as adrenocortical carcinoma, pheochromocytoma, hormone-producing adenoma or metastasis. However, less commonly, it can be a manifestation of infection such as tuberculosis. The case is a 40-year-old male who emigrated from China two years ago, referred to the endocrine clinic after he was found to have a 3 cm right adrenal macroadenoma on MRCP after hospitalization for acute cholecystitis. The patient was also found to have positive Quantiferon, but CXR was clear. He was started on isoniazid therapy for latent tuberculosis and was later switched to rifampin postoperatively. One month after hospital discharge, he was evaluated by Endocrinology. Vital signs, including BP were normal with no symptoms of dizziness or orthostatic hypotension. He had no symptoms of adrenal insufficiency or excess. Electrolytes, renal, liver function tests, and CBC were within normal. Albumin was 4.3g/dL(RR 3.4-5). Fasting 8 AM labs: ACTH 9 pg/mL (RR 0-47), cortisol 10.10 ug/dL (RR 5.3-22.5), DHEA S 130 mcg/dL (RR 80-560), plasma metanephrines and normetanephrines and midnight salivary cortisol were normal, aldosterone 10 ng/dL, renin 1.49 ng/mL/h with ARR of 6.7. Adrenal CT w/wo contrast showed right adrenal mass with absolute washout 78% and relative washout 53% consistent with adenoma, as well as bilateral subcentimeter lipid rich adenomas and marked mesenteric lymphadenopathy. Mycobacterium tuberculosis complex spreads to the adrenal glands hematogenously. Clinical manifestations of adrenal insufficiency in tuberculosis may take years to take effect, after 90% of gland destruction occurs. The majority of patients with active or recently acquired disease (&amp;lt;2 years) have bilateral adrenal enlargement, while calcification and atrophy is found with remote infection or inactive disease. The adrenals can be enlarged in patients with pulmonary tuberculosis even without active involvement of the glands solely due to stress and inflammation. The hypothalamic-pituitary-adrenal (HPA) axis can be activated or even under-activated in active pulmonary tuberculosis. Cortisol levels return to baseline after anti-tuberculous treatment. Rarely tuberculosis can cause adrenal incidentaloma. Adrenal biopsy is not necessary for primary adrenal insufficiency with bilateral adrenal enlargement in a patient with proven extra-adrenal tuberculosis. However, about 12% of patients with adrenal tuberculosis have no evidence of active extra-adrenal tuberculosis. Adrenal biopsy was refused but is generally necessary in these patients to prove adrenal involvement by tuberculosis. Our case highlights the fact that tuberculosis should be considered in the differential of adrenal masses. Reference: Fassnacht M, Arlt W, Bancos I, et al. Management of adrenal incidentalomas: European Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors. Eur J Endocrinol. 2016 Aug;175(2): G1-G34. doi: 10.1530/EJE-16-0467. PMID: 27390021. Presentation: No date and time listed

Detection rate and management of adrenal incidentalomas at Gozo General Hospital (GGH)

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Abstract #1181964: Quality Assessment of Adrenal Incidentaloma Management at an Academic Community Hospital

Adrenal incidentalomas are nodules found in cross-sectional imaging studies intended for a different purpose. There are guidelines provided by the combined 2009 American Association of Clinical Endocrinology (AACE) and American Association of Endocrine Surgeons (AAES), and the 2020 Endocrine Society for evaluation and management of adrenal incidentalomas. We sought to assess compliance with these guidelines at an academic community hospital. Guidelines recommend a complete biochemical evaluation to identify functioning nodules. Non-functioning nodules >4 cm should be resected, while those less than 4 cm require radiographic reevaluation 3-24 months later and annually for 1 to 2 years. Our electronic medical record was queried for patients with adrenal incidentaloma between 1/2017-1/2018. Univariable and multivariable logistic regression analysis was used to identify factors associated with biochemical evaluation. 1776 patients were identified. Those with a history of malignancy and previously identified adrenal nodules were excluded, leaving 235 patients. Complete biochemical evaluation was minimal for patients of all ages (16.0%), despite radiological identity (adenoma or indeterminate). 2 cm nodules were more likely to get a complete biochemical evaluation vs nodules 1-2 cm (11.5% vs 4.1%, p-value =0.003). Patients 18-50 were more likely to have a complete biochemical evaluation than those between 51-80 and >80 (20.0% vs 5.4% vs 0%, p-value =0.006). All age groups had less than 40.0% recommended repeat imaging and less than 7.0% had repeat imaging. Nodules >2 cm were more likely to have imaging recommendations and 16 month repeat imaging vs 1-2 cm nodules (21.8% vs 6.8% vs p-value =0.007). Adenomas were more likely to have imaging recommendations and 16 month repeat imaging vs indeterminate nodules (16.7% vs 8.2%, p-value =0.039). Only 3 patients had nodules >4 cm and 1 patient had surgery (lap adrenalectomy). Clinicians and radiologists are not following guidelines for adrenal incidentalomas. Clinicians and radiologists should be educated on biochemical evaluation and repeat imaging so patients in need of surgical resection are not missed. Radiographic reports should include imaging and biochemical recommendations for adrenal incidentalomas.

Management of incidental adrenal nodules: a survey of abdominal radiologists conducted by the Society of Abdominal Radiology Disease-Focused Panel on Adrenal Neoplasms.

Adrenal incidentalomas are common findings discovered at abdominal CT and MRI, yet the most appropriate management remains controversial and guidelines vary. The Society of Abdominal Radiology (SAR) Disease-Focused Panel on Adrenal Neoplasms sought to determine the practice patterns of abdominal radiologists regarding the interpretation and management of adrenal incidentalomas. An electronic survey consisting of eleven multiple choice questions about adrenal incidentalomas was developed and distributed to the email list of current and past SAR members. The response rate was 11.8% (423/3581) and most respondents were academic radiologists (80.6%). The 2017 American College of Radiology White Paper was the most used guideline, yet the management of indeterminate adrenal incidentalomas was highly variable with no single management option reaching a majority. Hormonal evaluation and endocrinology consultation was most often rarely or never recommended. The results of the survey indicate wide variability in the interpretation of imaging findings and management recommendations for incidental adrenal nodules among surveyed radiologists. Further standardization of adrenal incidentaloma guidelines and education of radiologists is needed.

Autonomous cortisol secretion : Laboratory artifact or disease?

Autonomous cortisol secretion was mentioned for the first time in 2016 in the European Guideline on the management of adrenal incidentalomas. Review of the state of knowledge on diagnosis, epidemiology, co-morbidities, mortality and treatment of autonomous cortisol secretion in comparison to non-hormone producing adenomas. Recommendation for clinical practice based on the current European guideline. Analysis of relevant clinical studies, discussion of basic literature and expert opinions. Autonomous cortisol secretion is aterm used to describe abnormal cortisol secretion diagnosed by apathological 1‑mg dexamethasone suppression test in patients with adrenal incidentaloma, but without clinical manifestation of overt Cushing's syndrome. It is associated with increased mortality and morbidity, especially hypertension, diabetes mellitus typeII, dyslipidemia and obesity. Adrenalectomy, as the only specific therapy option, should be considered in an interdisciplinary tumour board.

Low Rate of Guideline Adherence for the Diagnosis and Management of Adrenal Incidentalomas in the Nova Scotia Health Authority Central Zone

Abstract Background: Adrenal incidentalomas are prevalent and clinically significant, yet are often overlooked by clinicians. The objective of this study was to retrospectively examine the adherence to American College of Radiology (2017) and European Endocrine Society (2016) guidelines for the diagnosis and management of adrenal incidentalomas within a centre servicing a population of over 400,000. Methods: Relevant computed tomography (CT) and magnetic resonance (MR) scans from February 17th, 2019 to December 18th, 2019 were consecutively reviewed for the presence of adrenal incidentalomas. Radiographic reports and original imaging were reviewed to evaluate the completeness of reporting. A chart review was conducted to determine if biochemical investigations for cases were undertaken and whether referral to Endocrinology was made. Reports were checked for the inclusion of an addendum recommending Endocrinology referral. Results: A convenience sample of 148 cases were included in the study, with 176 distinct adrenal incidentalomas identified. Where relevant, attenuation values were provided for 20% of cases, and follow-up imaging was recommended in 59% of cases. Of the 124 cases where biochemical investigation was deemed appropriate, a complete work-up was conducted in 4% of cases, and 11% were referred to Endocrinology. Follow-up imaging was ordered appropriately in 36% of cases, and no cases had inappropriate follow-up imaging. The addendum was included for 19% of cases, and it did not impact biochemical investigation rates but did improve Endocrinology referral rates. Conclusions: There is poor adherence to guidelines for the diagnosis and management of adrenal incidentalomas within our study population. This poor adherence would be an ideal target for quality improvement initiatives, in order to minimize missed functional and malignant adrenal masses.

A Modern Assessment of Cancer Risk in Adrenal Incidentalomas: Analysis of 2219 Patients.

The aim of this study was to analyze the incidence of and risk factors for adrenocortical carcinoma (ACC) in adrenal incidentaloma (AI). AI guidelines are based on data obtained with old-generation imaging and predominantly use tumor size to stratify risk for ACC. There is a need to analyze the incidence and risk factors from a contemporary series. This is a retrospective review of 2219 AIs that were either surgically removed or nonoperatively monitored for ≥12 months between 2000 and 2017. Multivariate logistic regression was performed to define risk factors. ROC curves constructed to determine optimal size and attenuation cut-offs for ACC. 16.8% of AIs underwent upfront surgery and rest initial nonoperative management. Of conservatively managed patients, an additional 7.7% subsequently required adrenalectomy. Overall, ACC incidence in AI was 1.7%. ACC rates by size were 0.1%, 2.4%, and 19.5% for AIs of <4, 4 to 6, and >6 cm, respectively. The optimal size cut-off for ACC in AI was 4.6 cm. ACC risks by Hounsfield density were 0%, 0.5%, and 6.3% for lesions of <10, 10 to 20, and >20 HU, with an optimal cut-off of 20 HU to diagnose ACC. 15.5% of all AIs and 19.2% of ACCs were hormonally active. Male sex, large tumor size, high Hounsfield density, and >0.6 cm/year growth were independent risk factors for ACC. This contemporary analysis demonstrates that ACC risk per size in AI is less than previously reported. Given these findings, modern management of AIs should not be based just on size, but a combination of thorough hormonal evaluation and imaging characteristics.

SAT-168 Adrenal Incidentalomas: Impact of Patient Age on Referral Rates for Endocrine Evaluation

It is estimated that the prevalence of adrenal incidentaloma increases with age: ~3% of those aged 50 years, rising to 10% in those >70 years (1). Given the aging population together with increased utilisation of cross-sectional imaging in the UK (eg CT urogram, MR angiogram), we explored the proportion of patients with adrenal incidentaloma by age based on current imaging trends. Furthermore, there is no information currently available on the relationship between age and pattern of endocrine referrals. We extracted data for all CT and MRI scans from Jan 2018-Oct 2019 and used key phrases in radiology reports (eg adrenal adenoma/lesion/mass/nodule/incidentaloma, incidental adrenal, indeterminate adrenal) to identify potential lesions. We also extracted data on patient age and referral patterns as identified by a logged referral or an attendance (new or follow-up) to endocrine clinic 3 months post index scan, stratified by 10 year age groups. Where possible, we excluded false hits (eg no adrenal lesion). Preliminary data showed that, of the 2604 potential lesions identified by CT and MRI scans, 78.7% were on patients aged over 60 years. The numbers of identified lesions gradually increased with age to a peak in the 71-80 year age group after which these declined. Whilst patients younger that 60 years had fewer potential lesions identified, they were more likely to be referred to endocrine services (73 out of 55 patients; 13.2%) than those in the older age group (168 out of 2049; 8.2%; p<0.001). Indeed there was a statistically significant trend towards decreasing referral with age group (Chi-squared test for trend; p<0.001). In conclusion, patients over 60 years have a higher number of potential adrenal incidentalomas. However, this group is less likely to be referred for endocrine evaluation. This is particularly concerning given the large number of scans requested and the higher prevalence of incidentalomas in this age group. This study represents preparatory work on innovations to enhance case detection, particularly in the older age groups (2). 1. Fassnacht M, Arlt W, Bancos I, et al. Management of adrenal incidentalomas: European Society of Endocrinology Clinical Practice Guideline. Eur J Endocrinol. 2016;175:G1-G34 2. Hanna FWF, Issa BG, Lea SC, George C, Golash A, Firn M, Ogunmekan S, Maddock E, Sim J, Xydopoulos G, Fordham R, Fryer AA. Adrenal lesions found incidentally: how to improve clinical and cost-effectiveness. BMJ Open Quality. 2019;In press.

SAT-160 Evaluation of Life Style and Anthropometric Parameters in Patients with Nonfunctional Adrenal Incidentalomas

IntroductionAdrenal lesions that are found incidentally during routine imaging of people who do not have any complaints or physical findings related to adrenal gland are called adrenal incidentaloma (1,2). Incidentalomas appear more frequently with the increasing use of imaging techniques and increasing age. It is unclear why most of these masses emerged. It is controversial whether nonfunctional adrenal incidentalomas (NFAI) increase the risk of cardiovascular disease or metabolic syndrome or are more common in people with these diseases. In this study, we aimed to investigate whether lifestyle and body fat have an impact on the occurrence of NFAI.Materials and Methods100 patients with NFAI were included in the study. Control group consisted of 50 healthy and similar age groups. Physical activities of these groups (with the International Physical Activity Questionnaire Short Form), smoking were questioned and anthropometric measurements were made (Height, body weight, body mass index (BMI), neck, hip, waist circumference and body fat mass, fat percentage, total body water, fet free mass with bioimpedance method). Laboratory tests were examined from the patient file.ResultsFemale dominance was observed in patients with NFAI. BMI, waist circumference, hip circumference, neck circumference, total body fat percentage and mass and smoking were found to be higher in the patient group compared to the healthy group and a statistically significant difference was found. When a subgroup of patients with similar age and BMI among the patients and the control group were constituted (25-29,99 kg / m2) waist circumference and total fat mass were again significantly higher in the patient group compared to controls. In addition, there was a significant positive correlation between mass size and waist circumference, BMI, neck circumference, cortisol after 1 mg dexamethasone suppression test and a significant negative correlation with ACTH.ConclusionThe data obtained showed that body adiposity and smoking were higher in patients with NFAI. Also, ıt was shown that although the patients were regarded as nonfunctional, suppressibility of the cortisol decreases as the mass size of the incidentaloma increase.Resources1. Turkey Endocrinology and Metabolic Diseases Society of Adrenal and Gonadal Working Group. Adrenal and Gonadal Diseases Guide. 2019, pages 77–84.2. Fassnacht M, Arlt W, Bancos I, Dralle H, Newell-Price J, Sahdev A, et al. Management of adrenal incidentalomas: adrenal tumors. 2016; 175 (2): G1-G34.

Three-year follow up of adrenal incidentalomas in a New Zealand centre.

The international guidelines for management of adrenal incidentalomas (AI) are becoming more conservative. These changes are based on the growing body of evidence suggesting that non-functioning adenomas have a low likelihood of becoming functional or malignant over time. To follow up at least 100 patients for 3 years who were originally found to have benign adrenal adenomas which were non-functional or had subclinical Cushing syndrome (SCS). This study prospectively evaluated consecutive patients aged 18 years or older with benign adrenal incidentalomas (AI), not treated with adrenalectomy, which were non-functioning or had SCS. The initial and follow-up evaluation, including clinical assessment, hormonal investigations and imaging were coordinated via a standardised nurse-led AI clinic. Of 233 patients referred to the AI clinic, 101 patients met the inclusion criteria and completed 3-year follow up. Most of those excluded were due to incomplete initial or follow-up evaluation or were not true AI. Most AI either remained stable or decreased in size on repeat imaging, while 5% of patients had AI enlargement of >5 mm diameter. No patient developed features suggesting adrenal carcinoma. Ninety-two patients had an initial diagnosis of non-functioning adenoma and nine patients had SCS. After 3 years (range 2.9-4.7 years), five of the nine patients with SCS showed normalisation of cortisol parameters (44%), and five of the 92 non-functional AI patients developed SCS (5%). After 3 years of follow up, approximately half of patients with SCS normalised, while 5% of patients with initially non-functioning adenomas developed biochemical evidence of SCS. This study found a low likelihood of progressive hormonal excess with no evidence of malignancy developing on follow-up evaluation, providing support for the shift towards the more conservative approach to management of AI recommended in recent guidelines.

A nationwide survey of adrenal incidentalomas in Japan: the first report of clinical and epidemiological features.

The aim of this study was to reveal clear epidemiologic and clinical characteristics of incidentally discovered adrenal masses, termed adrenal incidentalomas (AIs), and to establish appropriate managemental and therapeutic regimens in Japan. This study had been originally carried out as a project of a research proposed on behalf of the Japanese Ministry of Health, Labour and Welfare, from 1999 to 2004. This nationwide multicenter study on AIs included 3,672 cases with clinically diagnosed AIs, involving 1,874 males and 1,738 females, with mean age 58.1 ± 13.0 years (mean ± SD). In the present study, we focused on the investigation of the real prevalence of various adrenal disorders with AI. The mean nodule size of AI based on computed tomography was 3.0 ± 2.0 cm. Compared to non-functioning adenomas (NFAs), tumor diameters were significantly larger in adrenocortical carcinomas (ACCs), pheochromocytomas, cortisol-producing adenomas (CPAs), myelolipomas, metastatic tumors, cysts, and ganglioneuromas (p < 0.01). Endocrinological evaluations demonstrated that 50.8% of total AIs were non-functioning adenomas, while 10.5%, including 3.6% with subclinical Cushing's syndrome, were reported as CPAs, 8.5% as pheochromocytomas, and 5.1% as aldosterone-producing adenomas. ACCs were accounted for 1.4% (50 cases) among our series of AIs. In conclusion, while almost 50 % of AIs are non-functional adenomas, we must be particularly careful as AIs include pheochromocytomas or adrenal carcinomas, because they may be asymptomatic. To our knowledge, this is the first and the largest investigation of AI, thus providing basic information for the establishment of clinical guidelines for the management of AI.

Management of adrenal incidentaloma: a DGH experience

Management of adrenal incidentaloma: a DGH experience

WFUMB position paper on the management incidental findings: adrenal incidentaloma.

Focal lesions of the adrenal glands are incidentally detected in approximately 5% of cases by modern imaging techniques. Fewer than 5% of these adrenal incidentalomas are malignant and approximately 10% have endocrine activity. Reliable differentiation of malignant versus benign and hormonally active versus nonfunctional adrenal incidentalomas significantly influences therapeutic management and the outcome of affected individuals. Therefore, each adrenal incidentaloma should undergo a standardized diagnostic work-up to exclude malignancy and endocrine activity. This position statement of the World Federation of Ultrasound in Medicine and Biology (WFUMB) summarizes the available evidence on the management of adrenal incidentaloma and describes efficient management strategies with particular reference to the role of ultrasound techniques.