November Introduction
Heidi James MD and Vanessa Cardy MD
Adrenal Tumors and Incidentalomas
- Adrenal incidentalomas occur on/in the adrenal glands and are unexpected findings
- Seen in 3-10% of CT scans and are more common due to aging population and better scans
- Usually unilateral, but can be bilateral (these are more likely to be pathologic)
- If mass is <1cm
- Not thought of as adrenal incidentalomas
- Do not need evaluation, unless suspect a functioning tumor
- If mass is > 1cm
- Approximately 80% of these tumors are completely benign and not worrisome
- Concerning tumors could be
- Adrenal carcinoma
- Mets from another cancer
- Secreting tumor
- Functioning adrenal adenoma
- Pheochromocytoma
- Hypercortisolemia
- Hyperaldosteronism
- Secreting tumors
- History and physical looking for signs/sx of hormone excess
- Pheochromocytoma
- Sweating
- Palpitations
- Elevated BP
- Hypercortisolemia
- Central obesity
- HTN
- Striae
- Hyperaldosteronism
- Aldosterone
- Hypokalemia
- HTN
- Labs for r/o functioning tumors
- R/O pheo for all patients with plasma metaneprhines or 24 hr urine metanephrine
- R/O cortisol secreting tumor for all patients with 24 hour dexamethasone suppression test
- If have HTN rule out hyperaldosteronism with renin and aldosterone levels
- Adrenal carcinomas
- Often larger than 4cm, tend to have ragged edges
- Consider adrenal washout CT to further characterize lesions
- Refer all cases for biopsy/resection
- Could also be metastases therefore be sure to look for primary if radiographic/bx results suspicious for same
- Benign adrenal incidentalomas
- Recommendations and evidence regarding follow-up is variable but overall consensus is that patients require ongoing follow-up (some lesions can grow and become hormonally active)
- Repeat imaging 3-6 months post-diagnosis, then qyear for 1-2 years
- Repeat hormonal testing qyear for at least 4 years
- Have low tolerance for re-imaging or re-testing in this patient population
References:
Fassnacht, Martin, 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." European Journal of Endocrinology 175.2 (2016): G1-G34. http://www.spcir.com/wp-content/uploads/2016/06/Guidelines_Europeias_de_incidentaloma_suprarenal_2016.pdf
Lee, Jung-Min, et al. "Clinical guidelines for the management of adrenal incidentaloma." Endocrinology and Metabolism 32.2 (2017): 200-218. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5503865/
Jason, Dylan S., and Sarah C. Oltmann. "Evaluation of an Adrenal Incidentaloma." Surgical Clinics (2019). https://www.ncbi.nlm.nih.gov/pubmed/31255202
