ADRENAL INCIDENTALOMAS

In medicine, an incidentaloma is a tumor (-oma) found by coincidence (incidental) without clinical symptoms or suspicion. It is a common problem with the current rate of imaging and is the name given to a lesion found by accident when doing x-rays or other imaging procedures for something else. These lesions or masses are found on the adrenal gland which sits on top of the kidney.

Up to 7% of all patients over 60 may harbor a benign growth, often of the adrenal gland, which is detected when diagnostic imaging is used for the analysis of unrelated symptoms. With the increase of "whole-body CT scanning" as part of health screening programs, the chance of finding incidentalomas is expected to increase. 37% of patients receiving whole-body CT scan may have abnormal findings that need further evaluation.

When faced with an unexpected finding on diagnostic imaging, the clinician faces the challenge to prove that the lesion is indeed harmless. Other tests are required to determine the exact nature of an incidentaloma.

What are the facts about adrenal masses discovered during imaging for non-adrenal related causes?
• It is the 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:
o Is the lesion hormonally active
o Is the lesion malignant

Tom Cawood states that evaluation of adrenal incidentalomas is costly, has high false positive rates and confers a risk of fatal cancer that is similar to the risk of the adrenal lesion becoming malignant and it’s time for a re-think of the whole matter. Cawood suggests that we-re-assess the performance of current clinical recommendations for the evaluation of an adrenal incidentaloma.

Cawood performed a literature review of electronic databases (Pubmed, Ovid and citation searches from key articles) from 1980 to 2008. Eligible studies were those deemed most applicable to the clinical scenario of a patient referred to an endocrinologist for assessment of an incidentally detected adrenal mass. Surgical series, histopathological series and oncological series were reviewed and most were excluded.

Results:
• The prevalence of functional and malignant lesions presenting as adrenal incidentaloma was similar to that quoted in most reviews, other than a lower incidence of adrenal carcinoma (1.9% vs 4.7%) and metastases (0.7% vs 2.3%).
• The development of functionality or malignancy during follow-up was rare (<1% style="font-weight: bold;">Bottom Line:
This argues for a review of current guidelines.

Current recommendations for evaluation of adrenal incidentaloma are likely to result in significant cost, both financial and emotional, due to high false-positive rates.
The dose of radiation involved in currently recommended CT scan follow-up confers a risk of fatal cancer that is similar to the risk of the adrenal becoming malignant.


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