Page 1 - Management of the incidentally discovered adrenal mass

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CUA gUideline

Guidelines for the management of the incidentally discovered

adrenal mass

Anil Kapoor, MD, FRCSC; Topher Morris, BMSc; Ryan Rebello, MD, FRCSC
†
*
*
†
* Division of Urology, Department of Surgery, McMaster University, Hamilton, ON; Department of Radiology, McMaster University, Hamilton, ON

Cite as: Can Urol Assoc J 2011;5(4):241-7; DOI:10.5489/cuaj.11135 Definition of adrenal incidentaloma

Introduction The incidental adrenal mass is a serendipitously discovered
adrenal lesion, >1 cm, on radiologic examination done for
reasons other than to investigate for primary adrenal dis-
With advances in modern imaging technology, the presen- ease. Adrenal incidentaloma is excluded in patients with
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tation of an incidentally found adrenal mass (or inciden- known malignancy or high suspicion of malignant processes;
taloma) has become an increasingly common management it is also excluded in patients with clinically evident adrenal
scenario for endocrinologists and urologists. The prevalence disease or overt disease originally missed due to insufficient
of adrenal incidentalomas (AI) has been reported as high clinical examination. Review of the literature does not sup-
1,2
as 8% in autopsy series and 4% in radiologic series. As port a change in this definition.
improved imaging techniques become available and the
frequency of abdominal imaging increases, the radiologic Principles of evaluation
prevalence is expected to continue escalating, approaching
the autopsy series. Also concerning is the evidence support- The goals of initial workup for AIs are to distinguish benign
ing an increased prevalence with age, with the risk of finding from malignant processes, as well as nonfunctioning from
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an AI being more common in the later years of life. In a hyperfunctioning tumours. A complete evaluation allows the
rapidly aging society, the diagnosis and management of AI clinician to distinguish adrenocortical carcinoma, pheochro-
will become a more frequent task. As such, guidelines are mocytoma, primary aldosteronism, and Cushing‘s syndrome
useful to guide appropriate treatment. (which require surgical removal) from benign adenomas
(which can be followed clinically).
Methods As previously mentioned, incidental adrenal masses
present in 4% of computed tomography (CT) scans in the
To propose guidelines for the management of adrenal general population, and the risk of finding an AI increases
3,5
incidentalomas, the literature was reviewed in MEDLINE with age. Most of these lesions, likely >80%, are benign
and EMBASE from 1990 to 2010. We limited the search in nature; diagnostic imaging can be a powerful tool to
to English studies and studies with a sample size greater delineate these masses from their malignant counterparts. 6
than 20 patients. The National Institutes of Health (NIH) Many benign masses, such as myelolipomas, cysts and hem-
state of the science on incidental adrenal masses was also orrhages, have characteristic imaging phenotypes that can
reviewed, as it is the closest iteration to a formal guideline direct a specific diagnosis without further workup. Cortisol-
published to date. 4 secreting adenoma, aldosterone-secreting adenoma, pheo-
From the literature, the following definitions and prin- chromocytoma, adrenocortical carcinoma and metastatic
ciples were identified and reviewed: (1) Definition of disease account for most of the remaining AIs. 7
adrenal incidentaloma; (2) Principles of evaluation of AI; The optimal approach to evaluate a patient with an AI
(3) Indications for surgery in AI; (4) Follow-up for patients has not been clearly established. However, there is consen-
with an AI. sus within the literature that all incidental adrenal masses
initially require a comprehensive workup, including thor-

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