A Survey on Adrenal Incidentaloma in Italy¹

Abstract

The aim of this study was to perform a national survey on occasionally discovered adrenal masses [adrenal incidentalomas (AI)] under the auspices of the Italian Society of Endocrinology. This multicentric and retrospective evaluation of patients with AI includes 1096 cases collected in 26 centers between 1980 and 1995. Relevant information was obtained by means of a specifically tailored questionnaire. Of the 1096 forms received, 1004 were retained for final analysis. Patients were 420 males and 584 females, aged between 15-86 yr (median, 58 yr). Mass size (computed tomography measurement) ranged from 0.5-25 cm (median, 3.0 cm). Hormonal work-up demonstrated that 85% of the masses were nonhypersecretory, 9.2% were defined as subclinical Cushing's syndrome, 4.2% were pheochromocytomas, and 1.6% were aldosteronomas. Adrenalectomy was performed in 380 patients with removal of 198 cortical adenomas (52%), 47 cortical carcinomas (12%), 42 pheochromocytomas (11%), and other less frequent tumor types. Patients with carcinoma were significantly younger than patients with adenoma (median, 46; range, 17-84; vs. 57, 16-83 yr; P = 0.05). Adenomas were significantly smaller than carcinomas (3.5, 1-15 vs. 7.5, 2.6-25 cm; P < 0.001), and a cut-off at 4.0 cm had the highest sensitivity (93%) in differentiating between benign and malignant tumors. Hormonal work-up of patients with subclinical Cushing's syndrome showed low baseline ACTH in 79%, cortisol unsuppressibility after 1 mg dexamethasone in 73%, above normal urinary free cortisol in 75%, disturbed cortisol rhythm in 43%, and blunted ACTH response to CRH in 55%. Only 43% of patients with pheochromocytoma were hypertensive, and 86% showed elevated urinary catecholamines. All patients with aldosteronoma were hypertensive and had suppressed upright PRA. These results indicate that mass size is the most reliable variable in separating benign from malignant AI. Adrenalectomy should be recommended for AI greater than 4.0 cm because of the increased risk of malignancy, especially in young patients. Endocrine evaluation should be performed in all patients to identify silent states of hormone excess.

The clinical course of patients with adrenal incidentaloma: is it time to reconsider the current recommendations?

“…In the study group, nearly 5% of the patients were diagnosed with adrenal carcinoma or adrenal metastasis from extraadrenal tissues, whereas another 5% of the patients had pheochromocytoma. Our findings are in line with the data of the previous studies that reported on the etiology of adrenal incidentalomas (10,11).…”

“…As has previously been reported, SCS is the most common functional abnormality among patients with adrenal incidentalomas (10,23), which was also found in 11.3% of our study population. Several observational studies reported that subtle cortisol excess in SCS is associated with increased cardiovascular risk (24,25).…”

Management of adrenal incidentalomas: European Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors

“…Autopsy studies suggest a prevalence of clinically unapparent adrenal masses of around 2% (range 1.0-8.7%), which increases with age (5, 6, 7). Radiological studies report a frequency of around 3% in the age of 50 years, which increases up to 10% in the elderly (2,5,6,7,14,15,16). In childhood, adrenal incidentalomas are extremely rare.…”

Russian Association of Endocrinologists clinical practice guideline for adrenal incidentalomas differential diagnosis

“…Описаны протекающие с классическими гипертензивными кризами "ФХЦ", которые оказываются гормонально неактивными аде-номами коры надпочечника или, что гораздо хуже, АКР [8,21].…”

“…Основным критерием при формирова-нии показаний к операции долгое время являл ся размер новообразования, что при-водило, с одной стороны, к большому числу необоснованных вмешательств при опухолях более 3-4 см, с другой стороны, к недооцен-ке злокачественного потенциала образова-ний малого размера при метастатических поражениях и АКР. При изучении итальянско-го регистра [21] лишь 25% опухолей надпо-чечников более 4 см оказались злокаче-ственными. Одновременно авторы привели данные, что среди больных АКР опухоли менее 6 см составляли около 10% наблюде-ний; с другой стороны, среди всех опухолей надпочечника более 6 см в диаметре АКР соста вил только 20% (!).…”