Discrepancies in the Recommended Management of Adrenal Incidentalomas by Various Guidelines

Abstract

Adrenal incidentalomas are being discovered with increasing frequency, and their discovery poses a challenge to clinicians. Despite the 2002 National Institutes of Health consensus statement, there are still discrepancies in the most recent guidelines from organizations representing endocrinology, endocrine surgery, urology and radiology. We review recent guidelines across the specialties involved in diagnosing and treating adrenal incidentalomas, and discuss points of agreement as well as controversy among guidelines. Materials and Methods: PubMedÒ, ScopusÒ, EmbaseÔ and Web of ScienceÔ databases were searched systematically in November 2019 in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement to identify the most recently updated committee produced clinical guidelines in each of the 4 specialties. Five articles met the inclusion criteria. Results: There is little debate among the reviewed guidelines as to the initial evaluation of an adrenal incidentaloma. All patients with a newly discovered adrenal incidentaloma should receive an unenhanced computerized tomogram and hormone screen. The most significant points of divergence among the guidelines regard reimaging an initially benign appearing mass, repeat hormone testing and management of an adrenal incidentaloma that is not easily characterized as benign or malignant on computerized tomography. The guidelines range from actively recommending against any repeat imaging and hormone screening to recommending a repeat scan as early as in 3 to 6 months and annual hormonal screening for several years. Conclusions: After reviewing the guidelines and the evidence used to support them we posit that best practices lie at their convergence and have presented our management recommendations on how to navigate the guidelines when they are discrepant.

Clinicopathological features of adrenal malignancies: Analysis of hospital‐based cancer registry data in Japan

“…On the other hand, adrenal gland tumors found by chance during a physical examination or over the course of various diseases are collectively called adrenal incidentalomas. 5 The prevalence of adrenal incidentaloma approaches 3% in middle age but increases to as much as 10% in the elderly. 6 Of the adrenal incidentalomas with a pathological diagnosis, adrenal malignancies account for only 10% 7,8 but rapid developments in diagnostic imaging techniques, such as abdominal ultrasonography, computed tomography, and magnetic resonance imaging, have increased chances to find these rare tumors.…”

“…On the other hand, adrenal gland tumors found by chance during a physical examination or over the course of various diseases are collectively called adrenal incidentalomas 5 . The prevalence of adrenal incidentaloma approaches 3% in middle age but increases to as much as 10% in the elderly 6 .…”

Giant Adrenal Myelolipoma and Congenital Adrenal Hyperplasia: A Case Report and Review of the Literature

“…Varying approaches to endocrine testing have been described. Shenoy et al suggest endocrine screening for patients at high risk of associated endocrine dysfunction (hypertension, diabetes, pre-diabetes, young age, bilateral adrenal myelolipomas) [9], while Maas et al recommend hormonal screening of all incidentalomas with plasma free metanephrines, urinary fractionated metanephrines, and 1 mg dexamethasone suppression test [22].…”

The Role of Intraoperative Indocyanine Green (ICG) and Preoperative 3-Dimensional (3D) Reconstruction in Laparoscopic Adrenalectomy: A Propensity Score-matched Analysis

“…Since adrenalectomies usually account for a small part of a laparoscopic surgeon's practice, it has been suggested that LA should be performed in specialized centers only, by advanced laparoscopy experts and in a context of multidisciplinary management. 33 Moreover, the laparoscopic technique hampers the surgeon's ability to receive tactile feedback, which is traditionally used to discern tumor edges and identify vascular structures in open procedures. In addition, the retroperitoneal space is narrow and barely reachable by laparoscopy.…”