Is Follow-up of Adrenal Incidentalomas Always Mandatory?

Abstract

Adrenal masses are mainly detected unexpectedly by an imaging study performed for reasons unrelated to any suspect of adrenal diseases. Such masses are commonly defined as "adrenal incidentalomas" and represent a public health challenge because they are increasingly recognized in current medical practice. Management of adrenal incidentalomas is currently matter of debate. Although there is consensus on the need of a multidisciplinary expert team evaluation and surgical approach in patients with significant hormonal excess and/or radiological findings suspicious of malignancy demonstrated at the diagnosis or during follow-up, the inconsistency between official guidelines and the consequent diffuse uncertainty on management of small adrenal incidentalomas still represents a considerable problem in terms of clinical choices in real practice. The aim of the present work is to review the proposed strategies on how to manage patients with adrenal incidentalomas that are not candidates to immediate surgery. The recent European Society of Endocrinology/European Network for the Study of Adrenal Tumors guidelines have supported the view to avoid surveillance in patients with clear benign adrenal lesions <4 cm and/or without any hormonal secretion; however, newer prospective studies are needed to confirm safety of this strategy, in particular in younger patients.

An Adrenocortical Carcinoma Evolving After Nine Years of Latency From a Small Adrenal Incidentaloma

“…A few other cases [7,12], similar to our case, have been described in the literature where AI was indolent for many years but subsequently demonstrated malignancy. Such a development is rare and falls outside the purview of current guideline recommendations.…”

“…The prevalence of AI in autopsy series has varied from 1.05% to 8.7% [4]. Modern imaging modalities with higher resolution also report a similar prevalence of about 4.4-7.3%, with the elderly population reporting up to 10% prevalence [4,7,8]. AIs become increasingly common with advancing age, occurring unilaterally or sometimes bilaterally, and are more likely to be found on the left side as the latter could be more apparent to the radiologist [4].…”

“…An average (CT) scan follow-up exposes each patient to 23 mSv of ionizing radiation, which is equivalent to Hence, it follows from the above discussion that AIs of more than 4-6 cm threshold, growth of 5 mm or above in absolute diameter with more than 20% increase compared to baseline in a 6-24-month period, inhomogeneity or increased density of more than 10% HU, exhibiting excess hormone secretion can be considered for adrenalectomy. In reality, age, comorbidities, and risk-benefit of surgery versus watchful observation are weighed carefully by a multidisciplinary team and clinical judgment is applied to individual patient scenarios [7].…”

“…in 430-2,170 chance of causing malignancy. This is similar to the possibility of developing adrenal malignancy during a three-year follow-up of AI, and hence prolonged serial CT scan follow-up cannot be recommended, as the risk-benefit profile and cost-effectiveness become unfavorable[5,7].2021 Kohli et al Cureus 13(8): e16851. DOI 10.7759/cureus.16851…”

The Role of Biomarkers in Adrenocortical Carcinoma: A Review of Current Evidence and Future Perspectives

“…Many questions still remain unanswered. Malignant potential among small adrenal incidentalomas < 4 cm; frequency of surveillance; ectopic extra-adrenal ACC presentation of an already, according to some authors, ultrarare disease; the possibility of advancement to adrenocortical carcinoma after decades in previously defined adenoma; risk factors of occurrence and many others doubts need to be kept in mind [ 231 , 232 , 233 ]. We might expect the increase in incidentaloma incidence due to technical improvement, frequency of use and availability of imaging methods, although distinguishing benign from malignant adrenal tumor with already-established diagnosis remains an enormous challenge.…”