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• Adrenal masses discovered during imaging for non-adrenal related causes
• Commonest adrenal 'disorder'
• Found during 1-5% of abdominal CT scans
• 5-10% patients have non-functioning adrenal masses found at postmortem examination
• Male to female ratio is equal
• Most incidentalomas are benign and hormonally inactive
• Few patients require adrenalectomy
• Diagnostic assessment needs to evaluate:
  • Is the lesion hormonally active
  • Is the lesion malignant

Differential diagnosis in absence of prior malignancy

Adrenal metastases

• Adrenal gland is a common site for metastases
• Common primary sites are breast, lung, renal, melanoma, lymphoma
• Often bilateral
• If prior history of carcinoma then 10-40% of adrenal masses will be metastases
• Risk of malignancy increases with size
• Most malignant adrenal lesions are greater than 5 cm in diameter

Assessment of adrenal incidentalomas

• Assessment of function requires:
  • Plasma dihydroepiandosterone
  • 24 hour urinary catecholamines and metanephrines
  • Low dose dexamethasone suppression test
  • Serum ACTH
  • If hypertension and hypokalaemia - standing serum aldosterone to renin ratio
• Assessment of risk of malignancy requires:
  • CT or MRI scanning
  • On CT malignant lesions are irregular non-homogeneous and have high attenuation
  • On MRI malignant lesions have bright intensity on T2 weighed images
  • CT guided cytology may be useful
  • Need to exclude phaeochromocytoma prior to this procedure

Management of adrenal incidentalomas

• If lesion is functioning patient requires adrenalectomy
• Can be performed as either an open or laparoscopic procedure
• Malignant lesions are best managed by open surgery
• If non-functioning treatment depends on:
  • Size
  • Risk of malignancy
• If more than 5 cm or imaging suggests malignancy consider surgery
• If less than 5 cm or benign repeat CT at 3-6 months

Bibliography

Barzon L,  Boscaro M.  Diagnosis and management of adrenal incidentalomas.  J Urol 2000:  163:  395-407.

Brunt L M,  Moley J F.  Adrenal incidentaloma.  World J Surg 2001;  25:  905-913.

Graham D J,  McHenry C R.  The adrenal incidentaloma:  guidelines for evaluation and recommendations for management.  Surg Clin North Am 1998;  7:  749-764.

Murai M,  Baba S,  Nahashima J,  Tachibana M.  Management of incidentally discovered adrenal masses.  World J Urol 1999;  17:  9-14.

Young W K.  Clinical practice:  The incidentally discovered adrenal mass.  N Engl J Med 2007;  356:  601-610.

Last updated: 05 January 2008

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