The adrenal incidentaloma
- William F Young, Jr, MD, MSc
William F Young, Jr, MD, MSc
- Professor of Medicine
- Mayo Clinic College of Medicine
- Electron Kebebew, MD, FACS
Electron Kebebew, MD, FACS
- Senior Investigator
- Chief, Endocrine Oncology Branch
- National Cancer Institute
- Section Editors
- André Lacroix, MD
André Lacroix, MD
- Section Editor — Adrenal Disease
- Professor of Medicine
- University of Montreal, Quebec, Canada
- Sally E Carty, MD, FACS
Sally E Carty, MD, FACS
- Section Editor — Endocrine Surgery
- Professor, Chief, Division of Endocrine Surgery
- University of Pittsburgh School of Medicine
An adrenal incidentaloma is a mass lesion greater than 1 cm in diameter, serendipitously discovered by radiologic examination . This entity is the result of technological advances in imaging such as computed tomography (CT) and magnetic resonance imaging (MRI) and their widespread use in clinical practice. Discovery of an adrenal mass raises two questions that determine the degree of evaluation and the need for therapy :
●Is it malignant?
●Is it functioning?
The approach to the evaluation and management of adrenal incidentalomas is reviewed here. Detailed discussions of adrenal carcinoma and functioning adrenal tumors such as pheochromocytomas and aldosteronomas are found elsewhere. (See "Clinical presentation and evaluation of adrenocortical tumors" and "Clinical presentation and diagnosis of pheochromocytoma" and "Pathophysiology and clinical features of primary aldosteronism".)
Adrenal masses may be found incidentally when computed tomography (CT) scans or magnetic resonance imaging (MRI) is done for other reasons. In a study of 61,054 abdominal CT scans performed from 1985 to 1990, an incidental adrenal tumor (incidentaloma >1 cm) was detected in 259 patients (0.4 percent of all CT scans) . A subsequent study, utilizing higher resolution scanners, reported a prevalence of adrenal incidentaloma on abdominal CT of 4.4 percent . The prevalence of adrenal incidentaloma is higher in older patients (10 percent) .
- Young WF Jr. Clinical practice. The incidentally discovered adrenal mass. N Engl J Med 2007; 356:601.
- Grumbach MM, Biller BM, Braunstein GD, et al. Management of the clinically inapparent adrenal mass ("incidentaloma"). Ann Intern Med 2003; 138:424.
- Herrera MF, Grant CS, van Heerden JA, et al. Incidentally discovered adrenal tumors: an institutional perspective. Surgery 1991; 110:1014.
- Bovio S, Cataldi A, Reimondo G, et al. Prevalence of adrenal incidentaloma in a contemporary computerized tomography series. J Endocrinol Invest 2006; 29:298.
- Terzolo M, Stigliano A, Chiodini I, et al. AME position statement on adrenal incidentaloma. Eur J Endocrinol 2011; 164:851.
- Hedeland H, Ostberg G, Hökfelt B. On the prevalence of adrenocortical adenomas in an autopsy material in relation to hypertension and diabetes. Acta Med Scand 1968; 184:211.
- Angeli A, Osella G, Alì A, Terzolo M. Adrenal incidentaloma: an overview of clinical and epidemiological data from the National Italian Study Group. Horm Res 1997; 47:279.
- Barzon L, Scaroni C, Sonino N, et al. Incidentally discovered adrenal tumors: endocrine and scintigraphic correlates. J Clin Endocrinol Metab 1998; 83:55.
- Kasperlik-Zeluska AA, Rosłonowska E, Słowinska-Srzednicka J, et al. Incidentally discovered adrenal mass (incidentaloma): investigation and management of 208 patients. Clin Endocrinol (Oxf) 1997; 46:29.
- Young WF Jr. Management approaches to adrenal incidentalomas. A view from Rochester, Minnesota. Endocrinol Metab Clin North Am 2000; 29:159.
- Mantero F, Terzolo M, Arnaldi G, et al. A survey on adrenal incidentaloma in Italy. Study Group on Adrenal Tumors of the Italian Society of Endocrinology. J Clin Endocrinol Metab 2000; 85:637.
- Cawood TJ, Hunt PJ, O'Shea D, et al. Recommended evaluation of adrenal incidentalomas is costly, has high false-positive rates and confers a risk of fatal cancer that is similar to the risk of the adrenal lesion becoming malignant; time for a rethink? Eur J Endocrinol 2009; 161:513.
- Nieman LK. Approach to the patient with an adrenal incidentaloma. J Clin Endocrinol Metab 2010; 95:4106.
- Henley DJ, van Heerden JA, Grant CS, et al. Adrenal cortical carcinoma--a continuing challenge. Surgery 1983; 94:926.
- Dunnick NR, Korobkin M, Francis I. Adrenal radiology: distinguishing benign from malignant adrenal masses. AJR Am J Roentgenol 1996; 167:861.
- Young WF Jr. Conventional imaging in adrenocortical carcinoma: update and perspectives. Horm Cancer 2011; 2:341.
- Hamrahian AH, Ioachimescu AG, Remer EM, et al. Clinical utility of noncontrast computed tomography attenuation value (hounsfield units) to differentiate adrenal adenomas/hyperplasias from nonadenomas: Cleveland Clinic experience. J Clin Endocrinol Metab 2005; 90:871.
- Szolar DH, Korobkin M, Reittner P, et al. Adrenocortical carcinomas and adrenal pheochromocytomas: mass and enhancement loss evaluation at delayed contrast-enhanced CT. Radiology 2005; 234:479.
- Peña CS, Boland GW, Hahn PF, et al. Characterization of indeterminate (lipid-poor) adrenal masses: use of washout characteristics at contrast-enhanced CT. Radiology 2000; 217:798.
- Israel GM, Korobkin M, Wang C, et al. Comparison of unenhanced CT and chemical shift MRI in evaluating lipid-rich adrenal adenomas. AJR Am J Roentgenol 2004; 183:215.
- Groussin L, Bonardel G, Silvéra S, et al. 18F-Fluorodeoxyglucose positron emission tomography for the diagnosis of adrenocortical tumors: a prospective study in 77 operated patients. J Clin Endocrinol Metab 2009; 94:1713.
- Hennings J, Hellman P, Ahlström H, Sundin A. Computed tomography, magnetic resonance imaging and 11C-metomidate positron emission tomography for evaluation of adrenal incidentalomas. Eur J Radiol 2009; 69:314.
- Burt M, Heelan RT, Coit D, et al. Prospective evaluation of unilateral adrenal masses in patients with operable non-small-cell lung cancer. Impact of magnetic resonance imaging. J Thorac Cardiovasc Surg 1994; 107:584.
- Mazzaglia PJ, Monchik JM. Limited value of adrenal biopsy in the evaluation of adrenal neoplasm: a decade of experience. Arch Surg 2009; 144:465.
- Cook DM, Loriaux DL. The incidental adrenal mass. Am J Med 1996; 101:88.
- Jhala NC, Jhala D, Eloubeidi MA, et al. Endoscopic ultrasound-guided fine-needle aspiration biopsy of the adrenal glands: analysis of 24 patients. Cancer 2004; 102:308.
- Lee JE, Evans DB, Hickey RC, et al. Unknown primary cancer presenting as an adrenal mass: frequency and implications for diagnostic evaluation of adrenal incidentalomas. Surgery 1998; 124:1115.
- Welch TJ, Sheedy PF 2nd, Stephens DH, et al. Percutaneous adrenal biopsy: review of a 10-year experience. Radiology 1994; 193:341.
- Arellano RS, Harisinghani MG, Gervais DA, et al. Image-guided percutaneous biopsy of the adrenal gland: review of indications, technique, and complications. Curr Probl Diagn Radiol 2003; 32:3.
- Vanderveen KA, Thompson SM, Callstrom MR, et al. Biopsy of pheochromocytomas and paragangliomas: potential for disaster. Surgery 2009; 146:1158.
- Casola G, Nicolet V, vanSonnenberg E, et al. Unsuspected pheochromocytoma: risk of blood-pressure alterations during percutaneous adrenal biopsy. Radiology 1986; 159:733.
- McCorkell SJ, Niles NL. Fine-needle aspiration of catecholamine-producing adrenal masses: a possibly fatal mistake. AJR Am J Roentgenol 1985; 145:113.
- Tauchmanovà L, Rossi R, Biondi B, et al. Patients with subclinical Cushing's syndrome due to adrenal adenoma have increased cardiovascular risk. J Clin Endocrinol Metab 2002; 87:4872.
- Reznik Y, Lefebvre H, Rohmer V, et al. Aberrant adrenal sensitivity to multiple ligands in unilateral incidentaloma with subclinical autonomous cortisol hypersecretion: a prospective clinical study. Clin Endocrinol (Oxf) 2004; 61:311.
- Hsiao HP, Kirschner LS, Bourdeau I, et al. Clinical and genetic heterogeneity, overlap with other tumor syndromes, and atypical glucocorticoid hormone secretion in adrenocorticotropin-independent macronodular adrenal hyperplasia compared with other adrenocortical tumors. J Clin Endocrinol Metab 2009; 94:2930.
- Beuschlein F, Fassnacht M, Assié G, et al. Constitutive activation of PKA catalytic subunit in adrenal Cushing's syndrome. N Engl J Med 2014; 370:1019.
- Chiodini I, Morelli V, Masserini B, et al. Bone mineral density, prevalence of vertebral fractures, and bone quality in patients with adrenal incidentalomas with and without subclinical hypercortisolism: an Italian multicenter study. J Clin Endocrinol Metab 2009; 94:3207.
- Sereg M, Szappanos A, Toke J, et al. Atherosclerotic risk factors and complications in patients with non-functioning adrenal adenomas treated with or without adrenalectomy: a long-term follow-up study. Eur J Endocrinol 2009; 160:647.
- Morelli V, Reimondo G, Giordano R, et al. Long-term follow-up in adrenal incidentalomas: an Italian multicenter study. J Clin Endocrinol Metab 2014; 99:827.
- Morelli V, Eller-Vainicher C, Salcuni AS, et al. Risk of new vertebral fractures in patients with adrenal incidentaloma with and without subclinical hypercortisolism: a multicenter longitudinal study. J Bone Miner Res 2011; 26:1816.
- Reincke M. Subclinical Cushing's syndrome. Endocrinol Metab Clin North Am 2000; 29:43.
- Nieman LK, Biller BM, Findling JW, et al. The diagnosis of Cushing's syndrome: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2008; 93:1526.
- Valli N, Catargi B, Ronci N, et al. Biochemical screening for subclinical cortisol-secreting adenomas amongst adrenal incidentalomas. Eur J Endocrinol 2001; 144:401.
- Tsagarakis S, Kokkoris P, Roboti C, et al. The low-dose dexamethasone suppression test in patients with adrenal incidentalomas: comparisons with clinically euadrenal subjects and patients with Cushing's syndrome. Clin Endocrinol (Oxf) 1998; 48:627.
- Mantero F, Arnaldi G. Investigation protocol: adrenal enlargement. Clin Endocrinol (Oxf) 1999; 50:141.
- Emral R, Uysal AR, Asik M, et al. Prevalence of subclinical Cushing's syndrome in 70 patients with adrenal incidentaloma: clinical, biochemical and surgical outcomes. Endocr J 2003; 50:399.
- Toniato A, Merante-Boschin I, Opocher G, et al. Surgical versus conservative management for subclinical Cushing syndrome in adrenal incidentalomas: a prospective randomized study. Ann Surg 2009; 249:388.
- Motta-Ramirez GA, Remer EM, Herts BR, et al. Comparison of CT findings in symptomatic and incidentally discovered pheochromocytomas. AJR Am J Roentgenol 2005; 185:684.
- Kopetschke R, Slisko M, Kilisli A, et al. Frequent incidental discovery of phaeochromocytoma: data from a German cohort of 201 phaeochromocytoma. Eur J Endocrinol 2009; 161:355.
- Lenders JW, Pacak K, Walther MM, et al. Biochemical diagnosis of pheochromocytoma: which test is best? JAMA 2002; 287:1427.
- Sawka AM, Jaeschke R, Singh RJ, Young WF Jr. A comparison of biochemical tests for pheochromocytoma: measurement of fractionated plasma metanephrines compared with the combination of 24-hour urinary metanephrines and catecholamines. J Clin Endocrinol Metab 2003; 88:553.
- Craig WD, Fanburg-Smith JC, Henry LR, et al. Fat-containing lesions of the retroperitoneum: radiologic-pathologic correlation. Radiographics 2009; 29:261.
- Mermejo LM, Elias Junior J, Saggioro FP, et al. Giant adrenal myelolipoma associated with 21-hydroxylase deficiency: unusual association mimicking an androgen-secreting adrenocortical carcinoma. Arq Bras Endocrinol Metabol 2010; 54:419.
- Liao CH, Lai MK, Li HY, et al. Laparoscopic adrenalectomy using needlescopic instruments for adrenal tumors less than 5cm in 112 cases. Eur Urol 2008; 54:640.
- Thompson GB, Grant CS, van Heerden JA, et al. Laparoscopic versus open posterior adrenalectomy: a case-control study of 100 patients. Surgery 1997; 122:1132.
- Gonzalez RJ, Shapiro S, Sarlis N, et al. Laparoscopic resection of adrenal cortical carcinoma: a cautionary note. Surgery 2005; 138:1078.
- Saunders BD, Doherty GM. Laparoscopic adrenalectomy for malignant disease. Lancet Oncol 2004; 5:718.
- Porpiglia F, Fiori C, Daffara F, et al. Retrospective evaluation of the outcome of open versus laparoscopic adrenalectomy for stage I and II adrenocortical cancer. Eur Urol 2010; 57:873.
- Brix D, Allolio B, Fenske W, et al. Laparoscopic versus open adrenalectomy for adrenocortical carcinoma: surgical and oncologic outcome in 152 patients. Eur Urol 2010; 58:609.
- Leboulleux S, Deandreis D, Al Ghuzlan A, et al. Adrenocortical carcinoma: is the surgical approach a risk factor of peritoneal carcinomatosis? Eur J Endocrinol 2010; 162:1147.
- Miller BS, Ammori JB, Gauger PG, et al. Laparoscopic resection is inappropriate in patients with known or suspected adrenocortical carcinoma. World J Surg 2010; 34:1380.
- Libè R, Dall'Asta C, Barbetta L, et al. Long-term follow-up study of patients with adrenal incidentalomas. Eur J Endocrinol 2002; 147:489.
- Bülow B, Jansson S, Juhlin C, et al. Adrenal incidentaloma - follow-up results from a Swedish prospective study. Eur J Endocrinol 2006; 154:419.
- Barzon L, Scaroni C, Sonino N, et al. Risk factors and long-term follow-up of adrenal incidentalomas. J Clin Endocrinol Metab 1999; 84:520.
- Bilateral masses
- EVALUATION FOR MALIGNANCY
- Imaging phenotype
- - CT scan
- - MRI
- Imaging characteristics
- - Benign adenomas
- - Pheochromocytomas
- - Adrenocortical carcinoma
- - Adrenal metastases
- - Other
- Fine-needle aspiration biopsy
- EVALUATION FOR HORMONAL SECRETION
- Subclinical Cushing's syndrome
- - Clinical manifestations
- - Diagnosis
- Unilateral adrenal masses
- Bilateral adrenal masses
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS