adrenal incidentalomas

• 4% of Pts undergoing abdominal CT scan have incidentally discovered adrenal mass;
• prevalence ↑ with age

Differential diagnosis

• Nonfunctioning mass:
  • adenoma,
  • cysts,
  • abscesses,
  • granuloma,
  • hemorrhage,
  • lipoma,
  • myelolipoma,
  • primary or metastatic malignancy
• Functioning mass:
  • pheochromocytoma,
  • adenoma (cortisol, aldosterone, sex hormones),
  • other endocrine tumor,
  • carcinoma

Hormonal workup (EJE 2016;175:G1; NEJM 2021;384:1542)

一般不做 bx

• Rule out subclinical Cushing’s Syndrome
  • in all Pts using 1 mg overnight DST (Sp 91%).
  • Abnormal results require confirmatory testing.
• Rule out hyperaldosteronism
  • if hypertensive w/ plasma aldo & renin (see above)
• Rule out pheochromocytoma
  • in ALL Pts (b/c of morbidity unRx’d pheo)
  • using 24-h urine fractionated metanephrines or plasma fractionated metanephrines
• Malignancy workup-adrenal incidentalomas

Follow-up

• If hormonal workup ⊖ and appearance benign,
• no further follow-up imaging needed,
• but controversial (Annals 2019;171:107)

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• biochemical testing to detect pheochromocytoma and excess cortisol secretion, and those who also have high blood pressure should undergo biochemical testing to detect primary hyperaldosteronism
• Patients with pheochromocytoma should undergo adrenalectomy after adequate presurgical alpha-blockade and beta-blockade, if necessary.
• Patients with mild autonomous cortisol excess and primary hyperaldosteronism may benefit from adrenalectomy, but treatment should be individualized.
• Nonfunctioning adrenal tumors that have an attenuation of 10 Hounsfield units or less on computed tomographic (CT) evaluation and that are smaller than 4 cm in greatest diameter generally do not warrant intervention or long-term follow-up.
• All other adrenal incidentalomas with indeterminate features on imaging may warrant additional imaging with contrast-enhanced CT,
  • magnetic resonance imaging with chemical-shift analysis,
  • positron-emission tomography–CT with 18F-fluorodeoxyglucose, or all of these tests.