The incidentally discovered adrenal mass

With the wider application of increasingly sensitive computed tomographic scans, more adrenal masses will be discovered incidentally. Because benign lesions of the adrenal are much commoner than malignant ones, an approach is needed to determine which incidentally discovered masses should be removed. The history and physical examination may guide the evaluation. Imaging studies and needle biopsies have limited value. If the history and physical findings do not suggest a diagnosis, an approach using the size of the mass, results of any cyst puncture, and a biochemical assessment may determine which patients should have surgery. This approach is based on the relative prevalence of benign and malignant clinically silent adrenal tumors.     

Management of incidentally discovered adrenal masses

The incidental discovery of adrenal masses in radiologic imaging studies is becoming increasingly common. Herein we present our experience with 59 cases of incidentally discovered and surgically removed adrenal masses. Of 59 adrenal incidentalomas, 15 cases were hypersecretory tumors, including 11 pheochromocytomas; only 3 were adrenocortical carcinomas. The prevalence of incidentally discovered adrenal masses and their differential diagnosis and management are discussed in a review of the literature.     

Assessment and treatment of incidentally discovered adrenal tumors

An incidentally discovered adrenal mass involves two main questions: the first is the evaluation of the hormonal activity of incidentalomas, that by definition are considered clinically silent. The second problem is to establish preoperatively the biologic behaviour of the masses, whether they are benign or malignant. An essential endocrinological screening of these masses includes the 24 hour urine VMA determination, serum potassium level, and a 1 mg overnight dexamethasone suppression test. Furthermore, the recent observation of a possible partial deficit of 21-hydroxylase suggests the advantage of 17-hydroxyprogesterone dosage after ACTH stimulation. At present no biochemical or radiologic markers can reliably distinguish benign from malignant masses. For this reason the association of imaging study with scintigraphy seems to be helpful, providing "concordant" or "discordant" patterns with CT images. As regard to therapeutic indications, the resection of all hypersecretive masses, proved malignant or increased in diameter tumors is suggested. As regards to biochemically silent lesions, the tumor size has been deemed to be the most helpful determinant of the nature although controversy remains over the size cutoff below which the masses can safely be presumed to be benign and therefore observed. The threshold to proceed surgically has been based on the perceived risk of cancer balanced against the operative risk. However it seems reasonable to recommend excision or surgical exploration for hormonally silent tumors greater than 3 cm, particularly in younger patients. According to personal opinion the laparoscopic approach might represent the gold standard in the treatment of incidentally discovered adrenal masses.     

Management of incidentally discovered adrenal masses and risk of malignancy

BACKGROUND: Incidentally discovered adrenal masses of more than 1 cm in size are relatively frequent, but the correct management of such lesions is not well established. METHODS: Between 1980 and 1999, 158 patients (73 men [46.2%] and 85 women [53.8%]; median age, 58 years) with adrenal incidentalomas of more than 2 cm in size were observed. Sixty-eight patients (43.0%) underwent adrenalectomy. The main reasons for surgery were (1) suspicious computed tomography (CT) scan or magnetic resonance imaging (MRI) appearance or no uptake at the 75-Se-norcholesterol scintigraphy (NCS; n = 22 patients), (2) an increase in the size of the mass of more than l cm (n = 15 patients), (3) subclinical endocrine hyperfunction (n = 14 patients), and (4) mass size of more than 5 cm (n = 22 patients), with imaging-guided fine-needle aspiration biopsy with spinal-type narrow-gauge needle (FNAB) that suggested malignancy (n = 5 patients). RESULTS: Pathologic examination showed 39 adrenocortical adenomas (57.4%), 20 adrenal malignancies (29.4%; carcinomas, 15; unsuspected metastases, 3; nonfunctioning malignant pheochromocytomas, 2), and 9 various benign lesions (13.2%). All masses that increased in size were benign. Seven malignant tumors (46.7%) were 3 to 4 cm in size, and 14 benign lesions (29.1%) were 5 to 6 cm in size. Sensitivity and specificity in the detection of malignancy were 100% and 100% for NCS (n = 34 patients) and FNAB (n = 19 patients), 75.0% and 93.7% for CT scan (n = 68 patients), and 87.5% and 100% for MRI (n = 26 patients), respectively. CONCLUSIONS: To differentiate benign and malignant incidentalomas, NCS and FNAB are more sensitive than CT scan and MRI; size criteria are of little value.     

What to do about the incidentally found adrenal mass

Summary The wider use of abdominal computerized axial tomography (CT) has led to the incidental discovery of increasing numbers of asymptomatic adrenal masses. The significance of these masses and the question as to their management have posed a new and important dilemma in clinical medicine. The majority of asymptomatic masses are benign and nonfunctional. The size of an adrenal mass on CT is still the most helpful finding in its evaluation. We propose that metabolically inactive lesions <3.5 cm in diameter on CT be followed with serial scans at 2, 6, and 18 months. After hormonal assessment, surgery should be carried out on lesions >6 cm, because there is a high probability for malignancy. For tumors 3.0–6.0 cm in diameter, management should be individualized. Under certain circumstances, especially in older and poor-risk patients, a conservative approach with more frequently obtained CT scans (6-week intervals) may be recommended. At the present time, magnetic resonance imaging (MRI) techniques cannot reliably distinguish benign from malignant adrenal masses and should be considered investigational in this setting, pending results of larger studies to determine its true sensitivity and specificity.     

Needle biopsy of incidentally discovered adrenal masses is rarely informative and potentially hazardous

INTRODUCTION: The role of fine needle aspiration (FNA) biopsy in patients with incidentally discovered adrenal masses is limited. However, image-guided biopsy continues to be performed in this setting, in some cases before biochemical workup. The purpose of this study was to review the value of FNA biopsy of adrenal masses in patients referred to a large university endocrine surgical practice. METHODS: Patients referred to the endocrine surgery service at our institutions from 1997 through 2006 for evaluation of an adrenal mass were identified and those who underwent needle biopsy were selected for analysis. RESULTS: Of the 347 patients evaluated for adrenal masses, 22 (6.3%) had undergone needle biopsy before referral. Clinical presentations were incidentaloma (n = 15), suspected metastasis (n = 4), and symptomatic large mass (n = 3). In 10 cases, a radiology report had either suggested a biopsy or stated that the mass was "amenable" to biopsy. In the 15 patients with incidentaloma, 12 (80%) had nondiagnostic biopsy results and 2 showed pheochromocytoma. Biopsies were diagnostic in 2 of 4 patients with suspected metastasis and in 1 of 3 patients with a large symptomatic mass. There were 3 biopsy-related complications: 1 liver hematoma, 1 hemothorax, and 1 duodenal hematoma. No biochemical testing for pheochromocytoma was performed before biopsy in 10 patients, 5 of whom were ultimately diagnosed with pheochromocytoma. Biopsy results did not alter clinical management in any of the 22 patients in this study. CONCLUSIONS: FNA biopsy is not useful in the diagnostic workup of patients with incidentally discovered adrenal masses and rarely alters management in patients with resectable adrenal metastases and primary adrenal malignancies. Furthermore, biopsy in this setting can also be potentially hazardous. Language that suggests biopsy of adrenal masses should be avoided in radiology reports.     

Noninvasive screening for pheochromocytoma in patients with an incidentally discovered adrenal mass: usefulness of provocative test with metoclopramide and 131I-metaiodobenzylguanidine scintigraphy

Pheochromocytoma accounts for approximately 25% of incidentally discovered adrenal masses. Certain diagnostic procedures (e.g., adrenal arteriography, needle biopsy of an adrenal mass), anesthesia and abdominal surgery may cause a sudden release of catecholamines from a pheochromocytoma and induce paroxysmal attacks of hypertension. In addition, pheochromocytoma is well known to cause unsuspected operating room deaths. Therefore, we must carefully separate this functioning neoplasm from other types of adrenal masses. In this study, we compared the results of noninvasive tests including (1) assay of urinary catecholamines and their metabolites, (2) a provocative pharmacologic test using metoclopramide (MCP test), and (3) 131I-metaiodobenzylguanidine (MIBG) scintigraphy to screen for pheochromocytoma in 10 consecutive patients with an incidentally discovered adrenal mass (6 pheochromocytomas and 4 non-functioning adrenocortical adenomas). We measured the 24-hour urinary excretion of catecholamines, metanephrines and vanillyl mandelic acid in all 10 patients; 5 were positive, 4 were negative and 1 was false-negative (sensitivity = 83%, specificity = 100%). The MCP test was performed in 7 patients; 3 were positive, 3 were negative and 1 was false-negative (sensitivity = 75%, specificity = 100%). MIBG scintigraphy was performed in 7 patients; 4 were positive, 1 was negative and 2 were false-negative (sensitivity = 67%, specificity = 100%). According to these results, all patients with an incidentally discovered adrenal mass should undergo a determination of the 24-hour urinary excretion of catecholamines and their metabolites, including metanephrines. If this urine assay is negative, other noninvasive tests including the MCP test and MIBG scintigraphy should be considered in selected patients with radiographic characteristics of pheochromocytoma.     

B超发现的未能扪及的睾丸肿块

探讨对于临床上体检不能扪及而由Ｂ超检查发现的睾丸肿块的诊治方法。对方法对有关病例的超声检查表现及其病理结果进行回顾性分析。结果近１０年来６００多例因子各种原因行阴囊超声检查的患者中,共发现１４例１６处体检未能扪及的睾丸肿块。患者平均年龄４２．４岁,肿块直径平均１２．１ｍｍ,除１例外其余肿块均表现为低回声团块。     

An incidentally discovered small and asymptomatic para-aortic paraganglioma

Preoperative diagnosis of asymptomatic paraganglioma is difficult due to the lack of specific symptoms. In this report, we present a rare case of a small and asymptomatic para-aortic paraganglioma. A 34-year-old woman who complained of back pain was admitted for further examination. No abnormal findings were observed on physical or laboratory examinations. An abdominal CT scan and an abdominal MRI incidentally noted a mass about 3 cm in diameter adjacent to the right edge of the inferior vena cava. The following aortic angiography showed the tumor with a feeding artery diverting directly from the aorta. The tumor was completely resected by laparotomy. The resected tumor, 3 x 3 x 3 cm in size, was soft, dark-reddish and encapsulated. Immunohistochemical examinations showed that it was positive for neuron-specific enolase, chromogranin A and adrenocorticotropin. Under these findings, the diagnosis of para-aortic paraganglioma was determined. Seven years after the operation, she remains asymptomatic and free of disease.     

Incidentally discovered adrenal masses

It is becoming increasingly common to discover adrenal masses incidentally on radiologic imaging studies. Adrenal masses are also occasionally found unexpectedly during operation. Herein, we review 10 cases of incidentally discovered adrenal masses which illustrate the experience with the treatment of these lesions in the past 8 years. A management plan based on this experience and a review of previously published data are discussed.