Adrenal cysts, medical jellies, what can you tell me about them?

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Official reprint from UpToDate® www.uptodate.com
©2010 UpToDate® Print | Back The adrenal incidentaloma
Authors
William F Young, Jr, MD, MSc
Norman M Kaplan, MD
Section Editor
Andre Lacroix, MD
Deputy Editor
Kathryn A Martin, MD
Last literature review version 18.1: January 2010 | This topic last updated: January 27, 2010 (More)
INTRODUCTION — An adrenal incidentaloma is a mass lesion greater than 1 cm in diameter, serendipitously discovered by radiologic examination [1]. This entity is the result of technological advances in imaging such as computed tomography (CT) and magnetic resonance imaging (MRI). Discovery of an adrenal mass raises two questions that determine the degree of evaluation and the need for therapy [2]:

•Is it malignant?
•Is it functioning?

The approach to the evaluation and management of adrenal incidentalomas is reviewed here. Detailed discussions of adrenal carcinoma, and functioning adrenal tumors such as pheochromocytomas and aldosteronomas are found elsewhere. (See “Clinical presentation and evaluation of adrenocortical tumors” and “Clinical presentation and diagnosis of pheochromocytoma” and “Clinical features of primary aldosteronism”.)

PREVALENCE — Incidental adrenal masses were long noted at autopsy. As an example, in a series of 739 autopsies, adrenal masses between 2 mm and 4 cm in size were present in 9 percent of normotensive patients and in 12 percent of patients who had hypertension [3].

During life, adrenal masses are found incidentally when CT or MRI is done for other reasons. The Mayo Clinic evaluated 61,054 abdominal CT scans performed from 1985 to 1990; adrenal masses were seen in 2066 patients (3.4 percent) [4]. An incidental adrenal tumor (incidentaloma, >1 cm) was seen in 259 patients (0.4 percent of all CT scans). A more recent study, utilizing higher resolution scanners, reported a prevalence of adrenal incidentaloma on abdominal CT of 4.4 percent [5].

Bilateral masses — Analyses from two large adrenal incidentaloma studies with 887 and 202 patients showed that bilateral masses were found in 10 to 15 percent of cases [6,7]. Bilateral adrenal masses can be seen with metastatic disease, congenital adrenal hyperplasia, cortical adenomas, lymphoma, infection (eg, tuberculosis, fungal), hemorrhage, ACTH-dependent Cushing’s, pheochromocytoma, amyloidosis, infiltrative disease of the adrenal glands, and ACTH-independent bilateral macronodular adrenal hyperplasia. In one study of 208 adrenal incidentaloma patients, 19 (9 percent) proved to have adrenal metastases; 10 of the 19 patients (53 percent) had bilateral disease [8].

In some patients with bilateral disease, one adrenal mass proves to be a nonfunctioning cortical adenoma while the contralateral adrenal mass is hormone-secreting [7]. In addition, adrenocortical hypofunction may occur in patients with bilateral adrenal masses. Therefore, all patients with bilateral adrenal masses should be screened for adrenocortical hyper- and hypo- function.

EVALUATION FOR MALIGNANCY — Primary adrenal carcinoma is quite rare, but other cancers, particularly lung cancers, may metastasize to the adrenal gland. The size and imaging characteristics (“imaging phenotype”) of the mass may help determine whether the tumor is benign or malignant [1,9].

Size — The maximum diameter of the adrenal mass is predictive of malignancy. This was illustrated in a study of 887 patients with adrenal incidentalomas from the National Italian Study Group on Adrenal Tumors [6]. Adrenocortical carcinomas were significantly associated with mass size, with 90 percent being more than 4 cm in diameter when discovered.

Adrenal mass size is also important because the smaller the adrenocortical carcinoma is at the time of diagnosis, the better the overall prognosis. In a retrospective review of 62 patients with adrenocortical carcinoma, five-year survival was approximately 16 percent overall, but much higher (42 percent) in patients with smaller tumors (stages I and II — confined to the adrenal gland) who were more likely to undergo curative resection [10]. (See “Clinical presentation and evaluation of adrenocortical tumors” and “Treatment of adrenocortical carcinoma”.)

In the report from the National Italian Study Group, a 4-cm cutoff had a 93 percent sensitivity of detecting adrenocortical carcinoma, even though specificity was limited (76 percent of masses larger than 4 cm in diameter were benign) [6,9]. In the Mayo Clinic study cited above, all 20 adrenal carcinomas were between 4 and 6 cm in diameter [4]. Therefore, surgical removal of adrenal masses larger than 4 cm should be considered, particularly in younger patients. Removing all tumors larger than 4 cm would result in the removal of eight benign tumors for each carcinoma, which is a reasonable ratio if adrenal carcinomas are not to be missed.

However, adrenal mass size should not be used as the only parameter to guide treatment. In particular, radiographic characteristics (imaging phenotype) also have strong predictive value [11]. (See ‘Imaging phenotype’ below.)

Imaging phenotype — MRI or CT with 2 to 3 mm cuts may allow prediction of the histologic type of the adrenal tumor, which is particularly important in the evaluation of masses that do not meet the size criterion for removal [1,6]. As an example, the lipid-rich nature of a cortical adenoma is helpful in distinguishing this benign tumor from carcinoma.

CT scan — On CT scanning, the density of the image (black is less dense) is attributed to X-ray attenuation. The intracytoplasmatic fat in adenomas results in low attenuation on nonenhanced CT; nonadenomas have higher attenuation in nonenhanced CT. The Hounsfield scale is a semiquantitative method of measuring x-ray attenuation. Typical precontrast Hounsfield unit (HU) values are adipose tissue = -20 to –150 HU, and kidney = 20 to 150 HU. If an adrenal mass measures <10 HU on unenhanced CT (ie, has the density of fat), the likelihood that it is a benign adenoma is nearly 100 percent. However, up to 30 percent of adenomas do not contain large amounts of lipid and may be indistinguishable from nonadenomas on nonenhanced CT scans.

A consensus panel noted that a homogeneous adrenal mass with a smooth border and an attenuation value <10 HU on unenhanced CT is very likely to be a benign adenoma [2]. This appears to be a reasonable CT HU cutoff based upon a retrospective analysis of 151 patients with adrenal masses who underwent both a noncontrast CT scan and adrenalectomy [12]. The mean HU (± SD) for adrenal adenomas/hyperplasia was significantly lower than for adrenal carcinomas, metastases, and pheochromocytomas (16.2 ± 13.6 versus 36.9 ± 4.1, 39.2 ± 15.2, and 38.6 ± 8.2, respectively).The only patients in the nonadenoma groups with a noncontrast CT HU <10 were those with myelolipomas (which were all less than -40 and therefore easily distinguishable). In this series, a noncontrast CT HU ≤ 10 or a combination of tumor size ≤4 cm and HU ≤ 20 excluded nonadenomas in 100 percent of cases.

On delayed contrast-enhanced CT, adenomas typically exhibit rapid contrast medium washout, whereas nonadenomas have delayed contrast material washout [12]. Ten minutes after administration of contrast, an absolute contrast medium washout of more than 50 percent was reported to be 100 percent sensitive and specific for adenoma, when patients with adenomas were compared with carcinomas, pheochromocytomas, and metastases [12–14]. Although imaging phenotype does not predict hormonal function, it does predict underlying pathology, and surgical resection should be considered in patients with adrenal incidentalomas that have a suspicious imaging phenotype [1].

MRI — Although CT remains the primary adrenal imaging procedure, MRI has advantages in certain clinical situations.

•Conventional spin-echo MRI is the most frequently used technique. Using low or mid-field-strength magnets, T1 and T2-weighted imaging can distinguish benign adenomas from malignancy and pheochromocytoma.
•On gadolinium-DPTA-enhanced MRI, adenomas demonstrate mild enhancement and a rapid washout of contrast, while malignant lesions show rapid and marked enhancement and a slower washout pattern.
•Chemical shift imaging (CSI) MRI is a form of lipid sensitive imaging based upon the principle that the hydrogen protons in water and lipid molecules resonate at different frequencies, referred to as “chemical shift” [15]. Benign adrenal cortical adenomas lose signal on out-of-phase images, but appear relatively bright on in-phase images.

Other — Positron emission tomography (PET) with either 18-fluoro-2-deoxy-D-glucose (FDG) [16] or 11C-metomidate (MTO) [17] can be helpful in selected patients (ie those with a prior history of malignancy) because of their high sensitivity for detecting malignancy. Because of cost and insufficient data to support their routine use, FDG-PET and MTO-PET are not recommended in the evaluation of the non-oncologic patient with an adrenal incidentaloma [1]. (See “Clinical presentation and evaluation of adrenocortical tumors”.)

Imaging characteristics — The imaging characteristics of adrenal masses are summarized here.

Benign adenomas —

•Round and homogeneous density; smooth contour and sharp margination [11]
•Diameter less than 4 cm; unilateral location
•Low unenhanced CT attenuation values (<10 HU) (picture 1)
•Rapid contrast medium washout (10 minutes after administration of contrast, an absolute contrast medium washout of more than 50 percent)
•Isointensity with liver on both T-1 and T-2 weighted MRI sequences
•Chemical shift evidence of lipid on MRI

Pheochromocytomas —

•Increased attenuation on nonenhanced CT (>20 HU)
•Increased mass vascularity (picture 2)
•Delay in contrast medium washout (ten minutes after administration of contrast, an absolute contrast medium washout of less than 50 percent)
•High signal intensity on T-2 weighted MRI (picture 3)
•Cystic and hemorrhagic changes
•Variable size and may be bilateral

Adrenocortical carcinoma —

•Irregular shape
•Inhomogeneous density because of central areas of low attenuation due to tumor necrosis (picture 4)
•Tumor calcification
•Diameter usually >4 cm
•Unilateral location
•High unenhanced CT attenuation values (>20 HU)
•Inhomogeneous enhancement on CT with intravenous contrast
•Delay in contrast medium washout (ten minutes after administration of contrast, an absolute contrast medium washout of less than 50 percent)
•Hypointensity compared with liver on T-1 weighted MRI and high to intermediate signal intensity on T-2 weighted MRI
•High standardized uptake value (SUV) on FDG-PET-CT study
•Evidence of local invasion or metastases.

Adrenal metastases —

•Irregular shape and inhomogeneous nature
•Tendency to be bilateral
•High unenhanced CT attenuation values (>20 HU) and enhancement with intravenous contrast on CT
•Delay in contrast medium washout (ten minutes after administration of contrast, an absolute contrast medium washout of less than 50 percent)
•Isointensity or slightly less intense than the liver on T-1 weighted MRI and high to intermediate signal intensity on T-2 weighted MRI (representing an increased water content)

Other — Adrenal cysts, adrenal hemorrhage, and myelolipoma are usually easily characterized because of their distinctive imaging characteristics.

Despite these radiographic characteristics, currently available imaging studies can be misleading. One study, as an example, evaluated 25 patients with potentially operable non-small cell lung cancer and a unilateral adrenal mass [18]. Thin-section MRI correctly predicted a malignant tumor in all four patients with histologically proven metastases, but 14 of 21 histologically benign masses were read as malignant and two as indeterminate.

Fine-needle aspiration biopsy — Cytology from a specimen obtained by fine-needle aspiration (FNA) biopsy cannot distinguish a benign adrenal mass from the rare adrenal carcinoma. It can, however, distinguish between an adrenal tumor and a metastatic tumor [19]. Thus, FNA biopsy may be indicated when there is a suspicion of cancer outside the adrenal gland, or in the patient undergoing a staging evaluation for a known cancer [20,21]. One report, as an example, evaluated patients with known lung cancer and an adrenal mass; FNA biopsy revealed a benign adrenal lesion in two-thirds of cases [11]. When the non-adrenal cancer is occult, most adrenal masses are incidentaloma cortical adenomas (91 of 95 in one study [22]). Thus, FNA biopsy is not useful in the routine evaluation of incidentalomas in patients suspected to have small non-adrenal cancers.

Image-guided fine-needle aspiration biopsy is relatively safe; the complication rate was 2.8 percent in one series of 277 biopsies [23]. The risks of this procedure include adrenal hematoma, abdominal pain, hematuria, pancreatitis, pneumothorax, formation of an adrenal abscess, and tumor recurrence along the needle track [23,24]. Also, the fine-needle aspiration biopsy of a pheochromocytoma may result in hemorrhage and hypertensive crisis, and the possibility of pheochromocytoma should always be ruled out by biochemical testing before fine-needle aspiration biopsy is undertaken [25,26].

EVALUATION FOR HORMONAL SECRETION — While most adrenal incidentalomas are nonfunctional, 10 to 15 percent secrete excess amounts of hormones [9,27]. The most complete analysis of this issue comes from a review of all 828 published articles on adrenal incidentalomas from 1980 to 2008 [27]. Only 20 of the 828 articles were selected as having met the strict criteria for a “true” adrenal incidentaloma; of these, only 9 had adequate data on both diagnosis and follow-up. Patients who were suspected as having cancer were excluded. Among the 1800 patients in these 9 series, these overall mean percentages of diagnoses were reported:

•Malignant — Primary adrenal carcinoma 1.9 percent, metases 0.7 percent
•Benign — Nonfunctioning 89.7 percent, subclinical Cushing syndrome 6.4 percent, pheochromocytoma 3.1 percent, primary aldosteronism 0.6 percent

Appropriate case detection tests should be performed if the patient has clinical features that are suggestive of increased adrenal function (table 1). However, subclinical Cushing’s syndrome and pheochromocytoma are sufficiently common that all patients with an adrenal incidentaloma should be tested for these disorders. In addition, hypertensive patients should be evaluated for an aldosteronoma even if the serum potassium concentration is normal.

Subclinical Cushing’s syndrome — Subclinical Cushing’s syndrome (ie, glucocorticoid secretory autonomy without clinical manifestations of Cushing’s syndrome) is the most frequent hormonal abnormality detected in patients with adrenal incidentalomas. Some adrenal incidentalomas secrete cortisol independently of ACTH [28], which may have clinically important consequences. In addition, cortisol secretion can be under the control of one or more aberrant hormone receptors in patients with unilateral adenomas or incidental bilateral ACTH-independent macronodular hyperplasia [29].

Clinical manifestations — Although these patients lack many of the usual stigmata of overt Cushing’s syndrome, they may have one or more of the effects of continuous autonomous cortisol secretion, including hypertension, diabetes, and a high incidence of vertebral fractures [30]. Those with subclinical Cushing’s syndrome are more likely to have hypertension, dyslipidemia, impaired glucose tolerance or type 2 diabetes mellitus, and evidence of atherosclerosis [31].

Diagnosis — In one large series of adrenal incidentalomas, hormonal evaluation in the patients with subclinical Cushing’s syndrome showed the following [9]:

•Low baseline secretion of corticotropin (ACTH) in 79 percent
•Lack of suppressibility of cortisol secretion after 1 mg dexamethasone in 73 percent
•Supranormal 24-hour urinary cortisol excretion in 75 percent
•Disturbed cortisol circadian rhythm in 43 percent
•Blunted plasma ACTH responses to corticotropin-releasing hormone in 55 percent

Because of a lack of sensitivity of most corticotropin (ACTH) assays at the lower part of the reference range, most centers rely on an alternate measure of autonomous cortisol secretion – the overnight dexamethasone suppression test (DST). Some centers use a higher dose of dexamethasone (eg, 3 mg rather than the standard 1 mg) to reduce false positive results [32] and others use a lower cortisol cutoff (eg, >2.2 mcg/dL [>60 nmol/L] rather than >5 mcg/dL [>138 nmol/L]) to reduce false negative results [33].

A study of the two-day low-dose DST [34] showed a gradation between autonomy and complete suppression of serum cortisol concentrations in 57 patients with adrenal incidentalomas (21 percent had undetectable serum levels of cortisol, 67 percent had values between 1 and 5 mg/dL, and 12 percent had values between 5 and 7.8 mg/dL). Thus, the question for the clinician should not be whether the cortical adenoma has glucocorticoid secretory activity. The question is whether the cortical adenoma has clinically significant glucocorticoid secretory activity. It is for this reason that many clinicians prefer to keep the 1-mg DST cortisol cutoff at >5 mcg/dL (>138 nmol/L).

If the post-overnight DST 8 AM serum cortisol concentration is abnormal, then additional tests should be considered to confirm glucocorticoid autonomy. Dehyroepiandrostenedione-sulfate (DHEA-S) is an adrenal androgen produced under the stimulation of ACTH. Thus, a low serum DHEA-S concentration suggests chronic suppression of ACTH. An undetectable level of serum ACTH is also supportive of the diagnosis of subclinical Cushing syndrome. Additional tests to consider when confirming glucocorticoid secretory autonomy include diurnal serum cortisol, baseline 24-hour cortisol excretion, and high-dose (8 mg) overnight DST.

Should all patients with subclinical Cushing’s syndrome undergo unilateral adrenalectomy? In the absence of a prospective randomized study, it is reasonable to consider that younger patients and those who have disorders potentially attributable to excess glucocorticoid secretion (eg, recent onset of hypertension, diabetes, obesity, and low bone mass) and have well-documented glucocorticoid secretory autonomy (eg, suppressed DHEA-S, low serum ACTH concentration, lack of suppression to high-dose overnight DST (8 AM serum cortisol >5 mcg/dL) are candidates for adrenalectomy. If adrenalectomy is performed, perioperative glucocorticoid coverage should be administered because of the risk of adrenal insufficiency, hemodynamic crisis, and death. Weight loss, improvement in hypertension and/or glycemic control, and normalization of markers of bone turnover are frequently found following unilateral adrenalectomy in patients with subclinical Cushing’s syndrome [35,36].

Pheochromocytoma — Approximately 3 percent of adrenal incidentalomas prove to be pheochromocytomas [27]. In the past it was thought that all patients with pheochromocytoma are symptomatic. However, with widespread use of computed imaging, pheochromocytomas are being discovered in the presymptomatic stage [37,38]. Although some recommend measurement of fractionated plasma metanephrines in all patients with adrenal incidentaloma [2], we suggest this measurement only when the pre-test probability of pheochromocytoma is high (eg, if the mass is vascular, dense, and has slow contrast washout), because while this test is very sensitive (95 to 98 percent), it is not very specific (89 to 95 percent) [27,39,40].

In patients with adrenal masses that, based on imaging phenotype, have a low probability for pheochromocytoma (eg, the adrenal mass is hypodense with rapid contrast washout), we suggest routine measurement of 24-hour urinary fractionated metanephrines and catecholamines. (See “Clinical presentation and diagnosis of pheochromocytoma”.)

Aldosteronomas — Aldosteronomas are rare (less than 1 percent) causes of an adrenal incidentaloma. However, because the majority of patients with primary aldosteronism are not hypokalemic, all patients with hypertension and an adrenal incidentaloma should be evaluated by measurements of plasma aldosterone concentration and plasma renin activity [1,2]. (See “Approach to the patient with hypertension and hypokalemia” and “Clinical features of primary aldosteronism”.)

TREATMENT

Unilateral adrenal masses — All patients with documented pheochromocytoma and primary aldosteronism should undergo surgery. (See “Treatment of pheochromocytoma in adults”.) Patients with aldosterone-producing adenomas should be offered the surgical option to cure aldosterone excess (see “Clinical features of primary aldosteronism”). Some patients with documented subclinical Cushing’s syndrome should be selected for surgery based upon the clinical parameters discussed above [41]. (See “Overview of the treatment of Cushing’s syndrome”, section on ‘Primary adrenal diseases’.)

Adrenal masses with either suspicious imaging phenotype or size larger than 4 cm should be considered for resection, because a substantial fraction will be adrenocortical carcinomas [2,10]. The clinical scenario and patient age frequently guide the management decisions in patients who have adrenal incidentalomas that fall on either side of the 4 cm diameter cutoff. As an example, most clinicians would advise resecting a uniform hypodense (9 HU) 3.7 cm adrenal incidentaloma in a 23-year-old woman, whereas most clinicians would choose serial imaging follow-up in an 83-year-old woman with a uniform hypodense (9 HU) 4.7 cm adrenal Incidentaloma. Before surgery all patients should undergo appropriate testing for functional tumors (see ‘Evaluation for hormonal secretion’ above).

Bilateral adrenal masses — The management of bilateral adrenal masses is different from that for unilateral masses. As an example, in cases of subclinical ACTH-independent bilateral macronodular adrenal hyperplasia, size is not an indication for surgery, as some can be as large as 5 to 10 cm with insufficient hormone production to necessitate surgery.

Laparoscopic adrenalectomy — Laparoscopic adrenal surgery is a safe, effective, and less expensive procedure than open adrenalectomy for patients with aldosteronomas, pheochromocytomas, cortisol-secreting adenomas, and adrenal incidentalomas [42]. (See “Treatment of adrenocortical carcinoma”.)

FOLLOW-UP — The optimal frequency and duration of follow-up for adrenal incidentalomas is uncertain and prospective data are scarce. It has even been suggested that no imaging follow-up is the optimal management strategy because of the concern about the radiation exposure related to CT [27]. However, in the absence of prospective studies, repeat imaging on at least one occasion (eg, at six to 12 months) is reasonable. Whether an additional imaging procedure is obtained at 24 months and the type of image obtained (eg, CT, MRI, or ultrasound) should be guided by the individual clinical circumstance, imaging phenotype, and clinical judgment. For example, a single repeat image is reasonable in patients who have no history of malignancy and who have small (less than 2 cm), uniform, hypodense, cortical nodules (ie, benign imaging phenotype). Whereas, repeat imaging is often recommended at three months after initial discovery in cases where the initial imaging phenotype is suspicious; the rationale is that many malignant lesions will grow in this interval, leading to earlier intervention.

Current practice is to remove any tumor that enlarges by more than 1 cm in diameter during the follow-up period. However, most adrenal masses that grow are not malignant.

The observation that autonomous function (glucocorticoid and catecholamine) not present at baseline may be detected at follow-up testing [43–45] has led to the recommendation for repeating hormonal evaluation annually for four years in cases where initial evaluation is negative [1,44,45]; however the yield and cost effectiveness of such testing is also unknown.

SUMMARY AND RECOMMENDATIONS

Evaluation — All patients with adrenal incidentalomas should be evaluated for the possibility of subclinical hormonal hyperfunction and cancer:

•A thorough history and physical examination are important in the initial assessment.
•A homogeneous adrenal mass <4 cm in diameter, with a smooth border, and an attenuation value <10 HU on unenhanced CT, and rapid contrast medium washout (eg, >50 percent at 10 minutes) is very likely to be a benign cortical adenoma.
•The imaging characteristics that suggest adrenal carcinoma or metastases include: irregular shape, inhomogeneous density, high unenhanced CT attenuation values (>20 HU), delayed contrast medium washout (eg, <50 percent at 10 minutes), diameter >4 cm, and tumor calcification. Other characteristics are described above. (See ‘Adrenocortical carcinoma’ above.)

•Pheochromocytoma should be excluded in all patients by measuring 24-hour urinary fractionated metanephrines and catecholamines. If the adrenal mass is vascular, or there are other features suggestive of pheochromocytoma, the preferred test is plasma fractionated metanephrines. (“Clinical presentation and diagnosis of pheochromocytoma-I”).
•Subclinical Cushing’s syndrome should be ruled out by performing the 1-mg overnight dexamethasone suppression test. To detect clinically significant glucocorticoid secretory autonomy, the post-overnight DST 8 AM serum cortisol concentration cutoff is >5 mcg/dL (>138 nmol/L).

An abnormal 1-mg overnight dexamethasone suppression is consistent with autonomous cortisol production; a finding that should be confirmed with serum ACTH concentration and a high-dose dexamethasone suppression test. (See “Establishing the diagnosis of Cushing’s syndrome”.)

•If the adrenal incidentaloma patient is hypertensive, a plasma aldosterone-to-plasma renin activity ratio and plasma potassium concentration should be obtained to screen for primary aldosteronism. (See “Approach to the patient with hypertension and hypokalemia”.)

Treatment

•We recommend surgery for all patients with biochemical documentation of pheochromocytoma (Grade 1B). The preoperative management of patients with pheochromocytoma is reviewed elsewhere. (See “Treatment of pheochromocytoma in adults”, section on ‘Medical preparation for surgery’.)

•We suggest surgery for patients with subclinical Cushing’s syndrome who are younger and who have disorders potentially attributable to autonomous glucocorticoid secretion (eg, recent onset of hypertension, diabetes, obesity, and low bone mass) (Grade 2C).
•We suggest surgery for patients with adrenal masses greater than 4 cm in diameter (Grade 2B). However, the clinical scenario, imaging characteristics, and patient age frequently guide the management decisions in patients who have adrenal incidentalomas that fall on either side of the 4 cm diameter cutoff. (See ‘Unilateral adrenal masses’ above.)

•If there is evidence that the mass could be a metastasis and after excluding pheochromocytoma with biochemical testing, we suggest performing a diagnostic CT-guided FNA biopsy (Grade 2C).

Follow-up

•We suggest a repeat imaging study at six to 12 months after initial discovery (Grade 2C). Whether an additional imaging procedure is obtained at 24 months and the type of image obtained (eg, CT, MRI, or ultrasound) should be guided by clinical judgment and imaging phenotype. The yield and cost effectiveness of such a strategy are not known.
•We suggest removal of any tumor that enlarges by more than 1 cm in diameter during the follow-up period (Grade 2C).
•We recommend repeat imaging at three months after initial discovery in cases where the imaging phenotype is suspicious; the rationale is that many malignant lesions will grow in this interval, leading to earlier intervention (Grade 1C).
•We suggest that hormonal testing be repeated annually for four years in cases where initial evaluation is negative, although the yield and cost effectiveness of such testing is also unknown. (Grade 2C). However, autonomous function (glucocorticoid and catecholamine) not present at baseline may be detected at follow-up testing.

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40.Sawka, AM, Jaeschke, R, Singh, RJ, Young, WF Jr. A comparison of biochemical tests for pheochromocytoma: measurement of fractionated plasma metanephrines compared with the combination of 24-hour urinary metanephrines and catecholamines. J Clin Endocrinol Metab 2003; 88:553.
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GRAPHICS
Hypodense adrenal adenoma
Abdominal CT showing a 1.5-cm round hypodense left adrenal cortical adenoma (arrow).
Courtesy of William F Young, Jr, MD. Pheochromocytoma silent
Abdominal CT showing an 8-cm left adrenal mass (arrow) discovered incidentally. Note the vascular and inhomogenous imaging characteristics of this mass. Biochemical evaluation was consistent with a clinically silent pheochromocytoma, which was confirmed at surgery.
Courtesy of William F Young, Jr, MD. Pheochromocytoma increase
MRI of the abdomen shows a 4.5-cm right adrenal pheochromocytoma (arrows). Upper panel: T1-weighted image. Lower panel: T2-weighted image shows increased signal intensity typical of a pheochromocytoma.
Courtesy of William F Young, Jr, MD. Adrenal cancer
Contrast-enhanced CT scan through the abdomen of a 56-year-old man reveals a complex solid and cystic, calcified mass (arrow) in the right suprarenal fossa extending into the adjacent liver. The tumor proved at surgery to be a carcinoma of the adrenal cortex.
Courtesy of Jonathan Kruskal, MD. Evaluation of the patient with an incidentally discovered adrenal mass
Diagnosis Suggestive Clinical Features Laboratory Tests
Pheochromocytoma Hypertension, Paroxysmal Symptoms (eg, palpitation, diaphoresis, headache, pallor, tremor) 24-hr urine:
fractionated metanephrines
fractionated catecholamines
Blood:
fractionated metanephrines
Cushing’s syndrome (CS) Central obesity, proximal muscle weakness, thin skin, supraclavicular fat pad, facial plethora For patients with symptoms of CS:
24-hr urinary free cortisol
For patients lacking symptoms of CS:
1-mg overnight dexamethasone suppression test
Primary aldosteronism Hypertension, hypokalemia
Plasma aldosterone concentration Plasma renin activity
Adrenocortical carcinoma Mass effect symptoms, symptoms related to excess glucocorticoid, mineralocorticoid, androgen, or estrogen secretion Serum dehydroepiandrosterone sulfate
Measures of clinically indicated steroid
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Woah. Let me have a look through this…

@Rarebear several years ago a CT scan revealed a small cyst on my adrenal gland. They found it by serendipity because they were looking for blood clots for reasons not relevant here. I sweated bullets, thinking that I had cancer and was already planning to refuse surgery or chemotherapy before my appointment with the endocrinologist.

He told me not to worry about it, everybody has them. I was checked a year later with no change so they told me to forget about the cyst. I did and that was 9 years ago with no problems or symptoms. It was a real relief and I would have worried less had I seen the article you quoted here. Good work.

Thanks. I was just being lazy, actually. I just copied and pasted the article.

@Rarebear I figured that you did that. The point is that you found it. When I researched the problem, the article didn’t exist. All I found was articles concerning cancer and the adrenal glands and they were not comforting. Thanks again,

@Ron_C No problem. It’s one advantage of having access to medical databases.