Highlights
- •Adrenal incidentalomas are clinically unsuspected lesions that are detected in adrenal glands during imaging procedures for other causes.
- •The two main clinical issues to be determined in this setting are the risk of malignancy and the hormonal activity of these lesions.
- •The treatment strategy can vary from simple follow-up to surgical resection.
Abstract
Adrenal incidentalomas are clinically unsuspected lesions that are detected in adrenal
glands during imaging procedures for other causes. With widespread use of imaging
− both computed tomography (CT) and magnetic resonance imaging (MRI) − adrenal incidentalomas
are now a common clinical problem. The two main clinical issues to be determined in
this setting are the risk of malignancy and the hormonal activity of these lesions.
The answers to these two questions, along with the clinical characteristics of each
individual patient and co-morbidities, will guide the treatment strategy, which can
vary from simple follow-up to surgical resection. The objective of this article is
to present updated information on the definition, prevalence, imaging and functional
features of adrenal incidentalomas and to provide a guide to their optimal assessment,
treatment and follow-up. This review collected, analyzed and qualitatively re-synthesized
information regarding: (1) the various clinical entities known as “adrenal incidentalomas”,
(2) the initial assessment of risk of malignancy, (3) the initial assessment of whether
the lesion is hormonally active or non-functioning, (4) the absolute and relative
indications for surgical treatment, (5) the follow-up of patients who are not deemed
to need surgical treatment after initial assessment, and (6) the post-operative follow-up
of patients who undergo surgical treatment. The evidence calls for clinicians to bear
in mind the Hippocratian advice “ωϕελέειν ή μη βλάπτειν” (“first do no harm”).
Abbreviations:
CT (computed tomography), HU (Hounsfield units, MRI magnetic resonance imaging), 18F-FDG (18fluoro-fludeoxyglucose), PET (positron emission tomography), ACTH (adrenocorticotropic hormone), DHEA-S (dehydroepiandrostenedione-sulfate), Δ4-Α (Δ4-androstenedione), UFC (urinary free cortisol), FNA (fine needle aspiration)Keywords
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References
- Incidentally discovered adrenal masses.Endocr. Rev. 1995; 16: 460-484
- Prevalence and natural history of adrenal 1516 incidentalomas.Eur. J. Endocrinol. 2003; 149: 273-285
- Risk factors and long-term 1514 follow-up of adrenal incidentalomas.J. Clin. Endocrinol. Metab. 1999; 84: 520-526
- The prevalence of adrenal incidentaloma in routine clinical practice.Endocrine. 2011; 40: 80-83
- Prevalence of adrenal incidentaloma in a contemporary computerized tomography series.J. Endocrinol. Invest. 2006; 29: 298-302
- The incidental adrenal mass on CT: prevalence of adrenal disease in 1,029 consecutive adrenal masses in patients with no known malignancy.AJR Am. J. Roentgenol. 2008; 190: 1163-1168
- Hormonal activity of adrenal incidentalomas-results from a long term follow-up study.Clin. Endocrinol. (Oxf.). 2009; 70: 674-679
- A survey on adrenal incidentaloma in Italy. Study group on adrenal tumors of the italian society of endocrinology.J. Clin. Endocrinol. Metab. 2000; 85: 637-644
- Clinical practice. The incidentally discovered adrenal mass.N. Engl. J. Med. 2007; 356: 601-610
- American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons Medical Guidelines for the Management of Adrenal Incidentalomas: executive summary of recommendations.Endocr. Pract. 2009; 15: 450-453
- Approach to the patient with an adrenal incidentaloma.J. Clin. Endocrinol. Metab. 2010; 95: 4106-4113
- Italian Association of Clinical Endocrinologists: AME position statement on adrenal incidentaloma.Eur. J. Endocrinol. 2011; 164: 851-870
- 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; 175: G1-G34
- Management of the clinically inapparent adrenal mass (incidentaloma).Ann. Intern. Med. 2003; 138: 424-429
- The clinically inapparent adrenal mass: update in diagnosis and management.Endocr. Rev. 2004; 25: 309-340
- Minor morphologic abnormalities of adrenal glands at CT: prognostic importance in patients with lung cancer.Radiology. 2005; 235: 517-522
- Adrenal incidentalomas.Best. Pract. Res. Clin. Endocrinol. Metab. 2012; 26: 69-82
- Glucose metabolism in patients with subclinical Cushing’s syndrome.Endocrine. 2012; 41: 415-423
- Novel insights into the genetics and pathophysiology of adrenocortical tumors.Front. Endocrinol. (Lausanne). 2015; 6: 96
- Bilateral adrenal incidentalomas differ from unilateral adrenal incidentalomas in subclinical cortisol hypersecretion but not in potential clinical implications.Eur. J. Endocrinol. 2014; 171: 37-45
- Abnormal responsiveness to dexamethasone-suppressed CRH test in patients with bilateral adrenal incidentalomas.J. Clin. Endocrinol. Metab. 2015; 100: 3478-3485
- Subclinical Cushing’s syndrome in patients with bilateral compared to unilateral adrenal incidentalomas: a systematic review and meta-analysis.Endocrine. 2016; 51: 225-235
- Imaging for the diagnosis of malignancy in incidentally discovered adrenal masses – a systematic review and meta-analysis.Eur. J. Endocrinol. 2016; 175: R51-64
- Differentiation of adrenal adenoma and nonadenoma in unenhanced CT: new optimal threshold value and the usefulness of size criteria for differentiation.Korean J. Radiol. 2007; 8: 328-335
- Imaging of adrenal incidentalomas: current status.AJR Am. J. Roentgenol. 2002; 179: 559-568
- Adrenal adenomas and nonadenomas: assessment of washout at delayed contrast enhanced CT.Radiology. 1998; 207: 369-375
- Characterization of lipidpoor adrenal adenoma: chemical-shift MRI and washout CT.AJR Am. J. Roentgenol. 2014; 202: 1043-1050
- Combined chemical shift imaging with early dynamic serial gadolinium-enhanced MRI in the characterization of adrenal lesions.AJR Am. J. Roentgenol. 2014; 203: 99-106
- High false positivity in positron emission tomography is a potential diagnostic pitfall in patients with suspected adrenal metastasis.World J. Surg. 2015; 39: 1902-1908
- 18F-FDG PET/CT in the characterization and surgical decision concerning adrenal masses: a prospective multicentre evaluation.Eur. J. Nucl. Med. Mol. Imaging. 2010; 37: 1669-1678
- Endocrine society, pheochromocytoma and paraganglioma: an endocrine society clinical practice guideline.J. Clin. Endocrinol. Metab. 2014; 99: 1915-1942
- Transcutaneous biopsy of adrenocortical carcinoma is rarely helpful in diagnosis potentially harmful, but does not affect patient outcome.Eur. J. Endocrinol. 2014; 170: 829-835
- Diagnosis of endocrine disease: the diagnostic performance of adrenal biopsy: a systematic review and meta-analysis.Eur. J. Endocrinol. 2016; 175: R65-80
- Subclinical Cushing’s syndrome in adrenal incidentalomas.Endocrinol. Metab. Clin. N. Am. 2005; 34: 423-439
- Subclinical Cushing’s syndrome in patients with adrenal incidentaloma: clinical and biochemical features.J. Clin. Endocrinol. Metab. 2000; 85: 1440-1448
- Long-term morphological hormonal, and clinical follow-up in a single unit on 118 patients with adrenal incidentalomas.Eur. J. Endocrinol. 2010; 162: 779-785
- The diagnosis of cushing’s syndrome: an endocrine society clinical practice guideline.J. Clin. Endocrinol. Metab. 2008; 93: 1526-1540
- Subclinical hypercortisolism and CT appearance in adrenal incidentalomas: a multicenter study from Southern Sweden.Endocrine. 2012; 42: 164-173
- The management of primary aldosteronism: case detection, diagnosis, and treatment: an endocrine society clinical practice guideline.J. Clin. Endocrinol. Metab. 2016; 101: 1889-1916
- The aldosterone to renin ratio in the evaluation of patients with incidentally detected adrenal masses.Endocrine. 2007; 32: 136-142
- Endocrine society, congenital adrenal hyperplasia due to steroid 21-hydroxylase deficiency: an endocrine society clinical practice guideline.J. Clin. Endocrinol. Metab. 2010; 95: 4133-4160
- Management of primary adrenal insufficiency: an endocrine society clinical practice guideline.J. Clin. Endocrinol. Metab. 2016; 101: 364-389
- Adrenocortical carcinoma.Endocr. Rev. 2014; 35: 282-326
- Adrenal cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up.Ann. Oncol. 2012; 23: vii131-vii138
- Endocrine society, treatment of Cushing’s syndrome: an endocrine society clinical practice guideline.J. Clin. Endocrinol. Metab. 2015; 100: 2807-2831
- Long-term survival after adrenalectomy for stage I/II adrenocortical carcinoma (ACC): a retrospective comparative cohort study of laparoscopic versus open approach.Ann. Surg. Oncol. 2014; 21: 284-291
- Recommended evaluation of adrenal incidentalomas is costly: has high falsepositive rates and confers a risk of fatal cancer that is similar to the risk of the adrenal lesion becoming malignant; time for a rethink?.Eur. J. Endocrinol. 2009; 161: 513-527
- Biochemical and clinical benefits of unilateral adrenalectomy in patients with subclinical hypercortisolism and bilateral adrenal incidentalomas.Eur. J. Endocrinol. 2015; 173: 719-725
Article info
Publication history
Published online: July 27, 2016
Accepted:
July 26,
2016
Received:
July 21,
2016
Identification
Copyright
© 2016 Elsevier Ireland Ltd. All rights reserved.
