Adrenal incidentaloma

State of the art

Abstract

Purpose: increased use of diagnostic imaging has led to the discovery of adrenal masses in patients without prior suspicion of a disease originated in adrenals, known as adrenal incidentaloma finding. Our purpose is to present a review of the topic to update the medical staff faced with a patient with this condition.

Data Source: a search with the MeSH term "adrenal incidentaloma" was conducted in Spanish, Portuguese and English in the Medline database since 2000. 352 references were obtained. Regional literature search with the term "incidentaloma" on Scielo, Lilacs and Bireme databases was performed. References to pituitary, liver and thyroid incidentalomas were excluded. 42 references were found in Lilacs and 1 article was excluded because they were liver incidentalomas. 37 references were found in Scielo and 5 were excluded, being treated thyroid, pituitary incidentalomas and a reference to renal carcinoma. Most references in our region are case reports and reviews with few original studies.

Study Selection: studies that referred to incidentalomas in other organs were excluded.

Results of data synthesis: adrenal incidentalomas can be benign like myelolipomas, fungal and mycobacterial infections or infrequent lesions as schwannomas. Adenomas which can be hormoneproducing and non-producing hormones can also be found. Also malignant lesions such as adrenal carcinomas and metastases can be found. In the presence of an adrenal incidentaloma larger than 4 cm, irregular edges, high attenuation of the lesion (in Hounsfield units) and a low percentage of washing in the contrast study, adrenal carcinoma should be suspected, in which case management is surgical once pheochromocytoma has been excluded. However, if the injury does not suggest malignancy, the clinician should wonder whether incidentaloma is or is not hormone- producing. In this regard we must assess the possibility of Cushing"(TM)s syndrome (via a suppression test with low doses of dexamethasone), pheochromocytoma (with measurement of metanephrines in urine or plasma) and if the patient is hypertensive, discard primary aldosteronism by measuring the aldosterone / renin ratio . According to these results the surgical treatment or clinical and imaging follow-up will be defined.

Conclusions: The adrenal incidentaloma has become a common disease in daily clinical practice of the internist. Although most of these lesions are not malignant and correspond to non-producing adenomas, the possibility of an endocrine disease should always be considered based on clinical and paraclinical features. Studies to acknowledge the epidemiology and etiology of this disease in our environment are required.