Adrenal incidentalomas

Abstract

The term adrenal incidentaloma (AI) is usually defined as an adrenal mass unexpectedly detected through an imaging procedure performed for reasons a priori unrelated to adrenal dysfunction or suspected dysfunction. The preferred approach to their management in terms of diagnosis, follow-up, and treatment remain controversial despite a state-of-the-science conference sponsored by the U.S. National Institutes of Health. Although most experts' recommendations tend to be relatively minor variations of the conference's approach, dissenting voices have been heard. Despite their frequent appearance, the challenge remains to recognize and treat the small percentage of AI that do pose a significant risk, either because of their hormonal activity or because of their malignant histology, while leaving the rest alone. Although the differential diagnosis of an incidentally discovered mass is quite extensive, most AIs are non-secreting cortical adenomas. The noninvasive differentiation of benign and malignant lesions depends upon imaging characteristics, and sometimes radiologic diagnosis can be definitive, but often it is not, Among function lesions, autonomous cortisol production seems to be the most common and may be associated with increased cardiovascular risk and clinical features of the "metabolic syndrome." Follow-up of cases in which a specific diagnosis is not made initially involves assessment for growth and development of hormonal function, but even here, controversy about the extent of evaluation persists.

Total testosterone levels are often more than three times elevated in patients with androgen-secreting tumours

“…Five per cent of all adrenal tumours are virilising and 50–70% are malignant with poor prognosis 42 43. In agreement with this, reported cases in table 1 had very large tumours, which is a marker of malignancy.…”

Subclinical Cushing’s syndrome in patients with bilateral compared to unilateral adrenal incidentalomas: a systematic review and meta-analysis

“…These clinical implications have been described in patients both with non-secreting AI and SCS [1,[5][6][7][8][9][10][11]. However, a higher percentage has been reported for patients with SCS, and this could be potentially associated with chronic exposure to slight cortisol excess [6-8, 11, 12].…”

Clinical Guidelines for the Management of Adrenal Incidentaloma

“…Hypersecretion of glucocorticoid, mineralocorticoid, sex steroids, and catecholamines not only causes clinical syndromes but can also be related to morbidity and premature mortality [18]. According to some studies, hypersecretion of hormones such as aldosterone, cortisol, or catecholamines has been found in 12% to 23% of adrenal incidentaloma patients without a history of malignant disease [19].…”