A multidisciplinary approach to the management of adrenal incidentaloma

ABSTRACT

Introduction:

An adrenal incidentaloma (AI) is an adrenal neoplasm incidentally discovered during an imaging unrelated to suspected adrenal disease. The aim of the present review is to offer practical guidance on the multidisciplinary approach of AIs.

Areas covered:

The prevalence of AI is high in the aging population (up to 5–8%); however, hormonally active or malignant conditions are rare. After the discovery of an AI, it is suggested to assess in parallel if the mass is potentially malignant and functionally active. The answer to the former question is mainly based on medical history (extra-adrenal malignancies, new-onset of signs or symptoms) and imaging (conventional radiology and/or nuclear medicine). The answer to the latter question is a complete endocrine evaluation of both cortical (glucocorticoids, mineralocorticoids) and medullary (catecholamines) secretion.

Expert opinion:

A multidisciplinary discussion is suggested for patients with adrenal disease, after the exclusion of nonfunctioning benign cortical adenoma, in order to plan a close and tailored follow-up for the suspected malignant or functioning forms. Surgery is advised for patients with malignant disease (adrenocortical cancer) or with clinically relevant secreting neoplasm (primary aldosteronism, Cushing’s syndrome, and pheochromocytoma).

KEYWORDS:

• Multidisciplinary approach
• adrenal incidentaloma
• adrenocortical cancer
• primary aldosteronism
• pheochromocytoma
• surgery

Article highlights

• Adrenal incidentalomas are adrenal neoplasms discovered during a procedure not performed for suspected adrenal disease. Their prevalence is age-dependent, the majority of them are non-secreting cortical adenomas.

• The detection of a clinically relevant hormone excess (glucocorticoids, mineralocorticoids, and catecholamines) should be ascertained with serum cortisol after 1 mg dexamethasone suppression test, aldosterone-to-renin ratio and plasma or urinary metanephrines.

• The first radiological evaluation should be dedicated to differentiate benign adenomas from malignant lesions (primary or secondary). Attenuation value <10 Hounsfield Unit in un-enhanced computed tomography is able to characterize lipid-rich benign cortical adenomas. We suggest the use of contrast-enhanced computed tomography, magnetic resonance, or nuclear medicine in the case of indeterminate AIs.

• Surgical treatment is indicated in secreting adrenal tumors leading to clinically significant hormone excess and in malignant neoplasms.

• A multidisciplinary approach is suggested in patients with suspect/indeterminate adrenal incidentaloma, in those with endocrine secretion and in the perioperative period, to decrease the need for unnecessary evaluation/surgery and to reduce/prevent post-operative complications.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.