Evaluation of the incidentally discovered adrenal mass

Surgical approach in adrenal incidentalomas: Report of thirteen cases and review of the literature

OBJECTIVE

The rate of adrenal incidentalomas detected in routine diagnostic imaging techniques is approximately 4-7%. Although the lesions are generally benign, carcinoma and functional adenomas can be diagnosed with careful clinic and laboratory evaluation.

MATERIAL AND METHODS

Data of 13 patients who underwent surgery for an adrenal mass between January 2010-June 2014 were analyzed retrospectively.

RESULTS

Seven (54%) patients were male, 6 (46%) were female, and the mean age was 38.2. The clinical diagnosis was pheochromacytoma in 5 patients (38.4%), non-functional adenoma in 5 (38.4), and metastatic lesion, Cushing syndrome, and adrenal carcinoma each in one patient (7.6%). Conventional open adrenalectomy was performed in 8 patients, while 5 patients underwent laparoscopic adrenalectomy.

CONCLUSION

Adrenal incidentalomas should be carefully evaluated for hormonal activity even if asymptomatic, and non-functional lesions should be considered as suspicious-for-malignancy. Laparoscopic adrenalectomy has become the gold standard for patients with a mass less than 6 cm, and without infiltration to adjacent organs.

Likelihood ratio of computed tomography characteristics for diagnosis of malignancy in adrenal incidentaloma: systematic review and meta-analysis

Purpose

To propose an evidence based diagnostic algorithm using mass characteristics to determine malignancy in patients with adrenal incidentaloma by CTscan.

Methods

A systematic review in Medline, Scopus, relevant reference books and desk searching was performed up to January 2016 with relevant reference checking. The summery estimates of sensitivity, specificity, positive and negative likelihood ratio of different characteristics were calculated in two groups of the articles investigating the cases without previous malignancy and the articles investigating the oncologic cases.

Results

Thirty six articles were included in this study. In the first group with no history of malignancy a positive and negative LR of 3.1 and 0.13 in 4 cm threshold and positive and negative LR of 2.85 and 0 in 10HU density were found. In the second group with history of malignancy positive and negative LR of 2.3 and 0.27 in 3 cm threshold and positive and negative LR of 3.6 and 0.08 in 20HU density were resulted.

Conclusion

The results retrieved in this study considering the limitations show that adrenal incidentaloma with a size less than 4 cm or a mass larger than 4 cm with density less than 10HU in the first group can be managed with imaging follow up. For masses larger than 4 cm with density more than 10HU another diagnostic procedure should be performed. In the second group an adrenal mass larger than 3 cm or less than 3 cm with density more than 20HU should go under operation. But masses smaller than 3 cm with less than 20HU density can be followed by imaging.

Surgical management of metastases to the adrenal gland: open, laparoscopic, and ablative approaches

The adrenal gland is a potential site of metastasis for various malignancies. Metastases to the adrenal gland are the second most common type of adrenal mass lesion after adenomas. Differentiation of a metastatic lesion from a primary adrenal lesion can be challenging and requires the selective use of radiologic imaging, serologic testing, and adrenal biopsy. In patients who present with an isolated adrenal metastasis, adrenalectomy is often considered to aid in cancer control. Numerous studies have reported improved survival with resection of solitary adrenal metastases for various types of primary tumors. Traditionally, open adrenalectomy was the preferred option for these patients. More recently, laparoscopic adrenalectomy has offered a minimally invasive approach, with its resultant advantages of improved perioperative parameters. Proper patient selection for the laparoscopic versus open approach remains paramount in deciding the best treatment for the individual patient.

Work-up of the functional adrenal mass

Evaluation of a functional adrenal mass may be initiated based on symptomatic presentation or the detection of an incidental adrenal mass. Recent literature suggests that 10% to 20% of adrenal incidentalomas demonstrate subclinical hormonal dysfunction, which may place patients at a higher risk for metabolic or cardiovascular disorders. Many diagnostic algorithms have been proposed for the evaluation of pheochromocytoma, Cushing's adenoma, aldosteronoma, and hormonally active adrenal cortical carcinoma. In this article, the available literature on functional adrenal masses is reviewed and up-to-date methods of efficient diagnosis are proposed.