A step by step approach in differential diagnosing of adrenal incidentaloma (epinephroma), (with comments on the new Clinical Practice Guidelines of the European Society of Endocrinology)

Abstract

Density less than 10 HU is in most cases characteristic of a lipid rich benign adenoma. More than 10 HU or/and history of malignancy raise the possibility for cancer. 1 mg dexamethasone test and plasma metanephrines should be done in all patients. If there is history of hypokalemia and/or resistant hypertension we test the plasma aldosterone to plasma renin ratio (ARR). Newer studies have shown that tumours even nonfunctioning and less than 4 cm may increase the metabolic risks so we may consider surgery at an earlier stage.

Diagnosing and managing adrenal incidentalomas

“…We recommend referring patients to an endocrinology clinician if the patient is a child or has: • a lesion 4 cm or greater • specific concerning findings on imaging such as inhomogeneity, irregular borders, or calcifications • a lesion that increases in size over time TABLE 4. Management and referral considerations for adrenal masses 1,5,18,20,24,29,30,32,33 Nonfunctioning adrenal adenoma smaller than 4 cm • bilateral adrenal masses • an abnormal screening hormonal evaluation • overt features of adrenal hormone excess on physical examination • a personal history of malignancy • a family history of endocrine tumors and/or genetic syndromes that are associated with adrenal masses. A discussion of management and referral recommendations is detailed in Table 4.…”