Adrena incidentaloma: Diagnosis & Treatments
Epidemiology
Adrenal incidentaloma is an adrenal mass lesion with a diameter of more than 1 cm incidentally detected by imaging. Adrenal incidentaloma is found in at least 2% of the population, and the prevalence increases with age. Adrenal incidentaolma is found in 1% of 40s and 7% of 70s.
Most adrenal incidentalomas are endocrine-inactive adrenocortical adenomas that do not release hormones. The prevalence of endocrine-inactive adrenocortical adenoma is 60 to 85% of endocrine-active adrenocortical adenoma, endocrine-active adrenocortical adenoma is 5 to 10% of cortisol producing adenoma, aldosterone-producing adenoma is 2 to 5%, and pheochromocytoma is 5 to 10 %. 2 to 5% of the unilateral adrenal mass is a malignant adrenocortical carcinoma and 15% is metastatic cancer at other sites.
Diagnosis
Diagnostic evaluation should be performed in patients with adrenal masses greater than 1 cm. Two important factors must be considered. First, does the tumor secrete hormones that can harm health? Second, is adrenal mass positive or malignant?
Hormone secretion by the adrenal mass is continuous and as the hormone secretion increases, the clinical symptoms also increase. Differentiating pheochromocytoma from catecholamine overload and adrenal medulla is an essential part of a series of precise diagnoses. Cushing's syndrome and primary aldosteronism are also the same. Adrenal incidentaloma may be associated with low levels of autonomous cortisol release, and patients may not have external clinical features of Cushing's syndrome. However, patients with adrenal incidentaloma may have one or more metabolic diseases (eg, obesity, type 2 diabetes, hypertension). There is still debate as to how to treat patients with mild or subclinical Cushing's syndrome. The overdose of DHEA, a precursor of adrenal androgen, occurs rarely and occurs when there is a malignant adrenocortical carcinoma.
When distinguishing malignant and benign adrenal masses, radiologic examination is fairly sensitive but specificity is not that high. CT is considered the best method for examining the adrenal gland. The larger the size of the mass, the higher the incidence of adrenocortical carcinoma, pheochromocytoma, and benign adrenal myelolipoma. However, size alone is not good indicator of malignancy. The sensitivity and the specificity are 80% and 60%, respectively. Also, the probability of cancer metastasis was similar in all sizes of adrenal masses. Tumor density in unenhanced CT is another diagnostic value. Most adrenocortical adenomas are rich in lipids and have low attenuation values in blastocysts. Usually benign tumors are round and internal homogeneous, and most malignant tumors consist of multiple lobes and are non-uniform. Pheochromocytoma and adrenomyelolipoma may also be multifocal and nonuniform. In addition, the contrast washout after 15 minutes of CT was more than 50% in benign tumors but less than 40% in malignant tumors with more vascularization. MRI is a preferred method for children, adolescents, and pregnant women because they can see adrenal glands at lower resolution than CT, but because patients are not exposed to radiation.
Adrenal incidentaloma is not an indication for fine-needle aspiration or CT-guided biopsy. This is because the FNA of Pheochromocytoma may lead to a life-threatening hypertensive crisis. In adrenocortical carcinomas, FNA may invade the tumor capsule and cause cancer metastasis along the needle. FNA is used only in patients with a history of nonadrenal malignancy, patients with adrenal masses that exclude pheochromocytoma, and when the outcome of FNA affects treatment. In 25% of patients with nonadrenal malignancy, tumors newly found by CT are not metastatic tumors.
Treatments
If a tumor or malignant tumor is suspected to be overdosed, surgical treatment should be done, or if adrenalectomy is not possible, or if the patient does not want it, take medication. It is very important to rule out glucocorticoid excesses before surgery because glucocorticoid replacement is necessary during and after surgery. If you choose to follow-up, radiologic testing and biochemical testing repeat after a year or so after the first test. However, if the radiologic findings are at the malignant / benign boundary, or if the hormone secretion level is unclear, check up earlier.
Adrenal incidentaloma is an adrenal mass lesion with a diameter of more than 1 cm incidentally detected by imaging. Adrenal incidentaloma is found in at least 2% of the population, and the prevalence increases with age. Adrenal incidentaolma is found in 1% of 40s and 7% of 70s.
Most adrenal incidentalomas are endocrine-inactive adrenocortical adenomas that do not release hormones. The prevalence of endocrine-inactive adrenocortical adenoma is 60 to 85% of endocrine-active adrenocortical adenoma, endocrine-active adrenocortical adenoma is 5 to 10% of cortisol producing adenoma, aldosterone-producing adenoma is 2 to 5%, and pheochromocytoma is 5 to 10 %. 2 to 5% of the unilateral adrenal mass is a malignant adrenocortical carcinoma and 15% is metastatic cancer at other sites.
Diagnosis
Diagnostic evaluation should be performed in patients with adrenal masses greater than 1 cm. Two important factors must be considered. First, does the tumor secrete hormones that can harm health? Second, is adrenal mass positive or malignant?
Hormone secretion by the adrenal mass is continuous and as the hormone secretion increases, the clinical symptoms also increase. Differentiating pheochromocytoma from catecholamine overload and adrenal medulla is an essential part of a series of precise diagnoses. Cushing's syndrome and primary aldosteronism are also the same. Adrenal incidentaloma may be associated with low levels of autonomous cortisol release, and patients may not have external clinical features of Cushing's syndrome. However, patients with adrenal incidentaloma may have one or more metabolic diseases (eg, obesity, type 2 diabetes, hypertension). There is still debate as to how to treat patients with mild or subclinical Cushing's syndrome. The overdose of DHEA, a precursor of adrenal androgen, occurs rarely and occurs when there is a malignant adrenocortical carcinoma.
When distinguishing malignant and benign adrenal masses, radiologic examination is fairly sensitive but specificity is not that high. CT is considered the best method for examining the adrenal gland. The larger the size of the mass, the higher the incidence of adrenocortical carcinoma, pheochromocytoma, and benign adrenal myelolipoma. However, size alone is not good indicator of malignancy. The sensitivity and the specificity are 80% and 60%, respectively. Also, the probability of cancer metastasis was similar in all sizes of adrenal masses. Tumor density in unenhanced CT is another diagnostic value. Most adrenocortical adenomas are rich in lipids and have low attenuation values in blastocysts. Usually benign tumors are round and internal homogeneous, and most malignant tumors consist of multiple lobes and are non-uniform. Pheochromocytoma and adrenomyelolipoma may also be multifocal and nonuniform. In addition, the contrast washout after 15 minutes of CT was more than 50% in benign tumors but less than 40% in malignant tumors with more vascularization. MRI is a preferred method for children, adolescents, and pregnant women because they can see adrenal glands at lower resolution than CT, but because patients are not exposed to radiation.
Adrenal incidentaloma is not an indication for fine-needle aspiration or CT-guided biopsy. This is because the FNA of Pheochromocytoma may lead to a life-threatening hypertensive crisis. In adrenocortical carcinomas, FNA may invade the tumor capsule and cause cancer metastasis along the needle. FNA is used only in patients with a history of nonadrenal malignancy, patients with adrenal masses that exclude pheochromocytoma, and when the outcome of FNA affects treatment. In 25% of patients with nonadrenal malignancy, tumors newly found by CT are not metastatic tumors.
Treatments
If a tumor or malignant tumor is suspected to be overdosed, surgical treatment should be done, or if adrenalectomy is not possible, or if the patient does not want it, take medication. It is very important to rule out glucocorticoid excesses before surgery because glucocorticoid replacement is necessary during and after surgery. If you choose to follow-up, radiologic testing and biochemical testing repeat after a year or so after the first test. However, if the radiologic findings are at the malignant / benign boundary, or if the hormone secretion level is unclear, check up earlier.
