Three‐year follow up of adrenal incidentalomas in a New Zealand centre

Abstract

Background The international guidelines for management of adrenal incidentalomas (AI) are becoming more conservative. These changes are based on the growing body of evidence suggesting that non‐functioning adenomas have a low likelihood of becoming functional or malignant over time. Aims To follow up at least 100 patients for 3 years who were originally found to have benign adrenal adenomas which were non‐functional or had subclinical Cushing syndrome (SCS). Methods This study prospectively evaluated consecutive patients aged 18 years or older with benign adrenal incidentalomas (AI), not treated with adrenalectomy, which were non‐functioning or had SCS. The initial and follow‐up evaluation, including clinical assessment, hormonal investigations and imaging were coordinated via a standardised nurse‐led AI clinic. Results Of 233 patients referred to the AI clinic, 101 patients met the inclusion criteria and completed 3‐year follow up. Most of those excluded were due to incomplete initial or follow‐up evaluation or were not true AI. Most AI either remained stable or decreased in size on repeat imaging, while 5% of patients had AI enlargement of >5 mm diameter. No patient developed features suggesting adrenal carcinoma. Ninety‐two patients had an initial diagnosis of non‐functioning adenoma and nine patients had SCS. After 3 years (range 2.9–4.7 years), five of the nine patients with SCS showed normalisation of cortisol parameters (44%), and five of the 92 non‐functional AI patients developed SCS (5%). Conclusion After 3 years of follow up, approximately half of patients with SCS normalised, while 5% of patients with initially non‐functioning adenomas developed biochemical evidence of SCS. This study found a low likelihood of progressive hormonal excess with no evidence of malignancy developing on follow‐up evaluation, providing support for the shift towards the more conservative approach to management of AI recommended in recent guidelines.

Adrenal Incidentaloma

“…Nine patients had evidence of ACS at diagnosis (defined as an elevated 24-hour UFC and a 1mg-DST), while the remaining 92 patients were diagnosed with a nonfunctioning AI. At 3 years, 5 of the 9 patients with ACS at diagnosis (44%) showed normalization of cortisol parameters, while 5 of the 92 patients with a nonfunctional AI developed ACS (5%) ( 268 ). Barzon et al reported the cumulative incidence of ACS after 1and 5 years as 3.8% and 6.6%, respectively ( 68 ).…”

Frequently asked questions and answers (if any) in patients with adrenal incidentaloma

“…Taking into account that the main consequences of subclinical hypercortisolism are arterial hypertension, metabolic disorders and diabetes, the New Zealand group coordinated by Goh et al suggests to evaluate case by case before engaging in too many investigations and wasting unnecessary resources [109]. We must keep in mind that in ACS the cortisol-related comorbidities, such as cardiovascular risk factors, impaired glucose or lipid metabolism, bone disease and the impaired quality of life [62,[110][111][112][113][114][115], are related to modest changes of cortisol secretion.…”

“…At the beginning of the study nine cases showed signs of cortisol excess. At 3 years, five of the nine cases of hyperfunction normalized, while the other five showed a subclinical cortisol secretion (5%) [ 109 ].…”

Attenuation Value in Adrenal Incidentalomas: A Longitudinal Study

“…A consistent cohort of patients present a subclinical autonomous cortisol secretion (ACS), without the full-blown clinical picture of overt hypercortisolism (6,7). Several studies reported a progression from a nonfunctioning adrenal incidentaloma (NFAI) to ACS in up to 11% of cases (8)(9)(10), especially in larger adenomas (11,12).…”