Evaluation of incidental adrenal mass

Diseases

Summary

Incidental adrenal masses are frequently encountered during imaging of the abdomen and chest, as the adrenals are typically included in inferior portions of chest computed tomographic (CT) exams. They are classified as hormonally active or nonfunctioning, and as malignant or benign.

The prevalence of clinically inapparent adrenal masses increases with age, being <1% for patients younger than 30 years of age and increasing to 7% in patients 70 years of age and older.[1]

Forty-one percent of incidental adrenal masses are adenomas, 19% metastases, 10% adrenocortical carcinomas, 9% myelolipomas, around 7% pheochromocytomas, and the remainder are mostly benign tumors (cysts, adrenolipomas, hematomas, leiomyomas, lymphangiomas).[2] [3] [4]

The prevalence of adrenal adenoma is 6% based on autopsy studies, and 4% based on abdominal computed tomography.[5]

Most hormonally active adrenal tumors causing Cushing syndrome, pheochromocytoma, or primary hyperaldosteronism are benign, but uncommonly they may be malignant.

Adrenocortical carcinoma, while rare, is frequently hormonally active.

Library

Workup of an adrenal mass incidentally found on imaging [Abbreviations: CT: computed tomography; CECT: contrast-enhanced CT; MRI: magnetic resonance imaging; CS-MRI: compressed sensing MRI; F-DOPA: 3,4-dihydroxy-6-(18)F-fluoro-l-phenylalanine; FDG: 18-fluoro-2-deoxyglucose; Ga/Cu DOTATATE: ⁶⁸Ga- or ⁶⁴Cu-DOTA-(Tyr3)-octreotate; FNAB: fine-needle aspiration (FNA) biopsy; HU: Hounsfield unit; MIBG: meta-iodobenzylguanidine; NP-59: iodine-131-6-beta-iodomethylnorcholesterol (or radio-iodine-labeled norcholesterol); PET: positron emission tomography; SUVmax: maximum standardized uptake value; US: ultrasound]
Incidentally discovered, 1.8 cm diameter, right adrenal mass in a 37-year-old man. Abdominal CT (A) depicts the mass as lipid-poor with atypical contrast enhancement; NP-59 scintigraphy done without dexamethasone suppression; (B) demonstrates a concordant pattern of imaging with right > left adrenal accumulation of iodocholesterol on the fifth and sixth days postinjection, compatible with a benign etiology
Left adrenal aldosteronoma depicted with dexamethasone suppression NP-59 imaging: 57-year-old woman with biochemical evidence of hyperaldosteronism and a left adrenal mass. Abdominal CT (A) demonstrates a 2 cm left adrenal mass (black arrow), anterior and posterior abdominal NP-59 scans (B and C) on the third day postinjection; anterior and posterior abdominal NP-59 scans (D and E) on the fifth day postinjection; abnormal left adrenal uptake (black arrows) occurs early, before day 5 postinjection (B and C); normal uptake in liver (L), bowel (B), and gallbladder (GB)
Meta-iodobenzylguanidine (MIBG) scan demonstrating intensely focal tracer activity in the left adrenal gland consistent with pheochromocytoma in a 56-year-old woman with HTN, elevated plasma norepinephrine levels, and a 3 cm left adrenal mass seen on cross-sectional anatomic imaging
Malignant, metastatic pheochromocytoma demonstrated by 123-I-meta-iodobenzylguanidine (MIBG) and CT in a 31-year-old woman after bilateral adrenalectomy and persistent HTN complicated by renal insufficiency and recent development of superior vena cava (SVC) obstruction; (A) anterior chest and abdomen scan. L = normal liver uptake while arrows depict multiple, abnormal foci of 123-1-MIBG in metastatic pheochromocytoma deposits in the mediastinum and para-aortic regions; (B) chest CT identifies the superior mediastinal mass responsible for SVC obstruction (white arrow)
18-fluoro-2-deoxyglucose (FDG) PET-CT: adrenal adenoma. 46-year-old man with squamous cell carcinoma of the neck (TxN1 tumor) status post-external beam radiation therapy; restaging PET-CT demonstrates low-attenuation, non-FDG avid, 3.7 cm left adrenal nodule consistent with adrenal adenoma; FDG PET study excluded distant metastasis to the adrenal gland
18-fluoro-2-deoxyglucose (FDG) PET-CT: adrenocortical carcinoma. 51-year-old woman with Cushing syndrome and large, multilobulated and intensely 18-F-FDG avid left adrenal mass and metastatic aortocaval and left para-aortic lymph nodes
Left adrenal metastasis (arrow) depicted by 18-fluoro-2-deoxyglucose (FDG) PET-CT (A-C) in a patient with a non-small cell lung cancer (arrow); corresponding chest (D) and abdominal (E) CT scans identify the lung primary and the adrenal metastasis (arrow)

Citations

Key Articles

Grumbach MM, Biller BM, Braunstein GD, et al. Management of the clinically inapparent adrenal mass ("incidentaloma"). Ann Intern Med. 2003 Mar 4;138(5):424-9.[Abstract][Full Text]
Young WF Jr. Clinical practice. The incidentally discovered adrenal mass. N Engl J Med. 2007;356:601-10.[Abstract]
Fassnacht M, Tsagarakis S, Terzolo M, et al. European Society of Endocrinology clinical practice guidelines on the management of adrenal incidentalomas, in collaboration with the European Network for the Study of Adrenal Tumors. Eur J Endocrinol. 2023 Jul 20;189(1):G1-42.[Abstract][Full Text]
Zeiger MA, Thompson GB, Duh QY, et al. The American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons medical guidelines for the management of adrenal incidentalomas. Endocr Pract. 2009 Jul-Aug;15(suppl 1):1-20.[Abstract][Full Text]
Expert Panel on Urological Imaging., Mody RN, Remer EM, et al. ACR Appropriateness Criteria® Adrenal Mass Evaluation: 2021 Update. J Am Coll Radiol. 2021 Nov;18(11s):S251-S267.[Abstract][Full Text]

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