Recommended 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; time for a rethink?

Abstract

Current recommendations for evaluation of adrenal incidentaloma are likely to result in significant costs, 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. This argues for a review of current guidelines.

Pros and cons of dexamethasone suppression test for screening of subclinical Cushing’s syndrome in patients with adrenal incidentalomas

“…These findings put more value in specificity than sensitivity and this fits well with the general concept of screening in a roughly asymptomatic population, such as patients with clinically inapparent adrenal adenomas (6). Since the long-term consequences of the mild cortisol excess that 11 characterizes subclinical Cushing's syndrome have not been unequivocally defined, use of stringent criteria to diagnose this condition is recommended to reduce false positive results that may have negative psychological and economic consequences, leading to further testing or even unnecessary surgery (25). The limit of 50 nmol/L, on the other hand, reasonably excludes functional autonomy reducing remarkably the post-test probability of this event.…”

Nebenniereninsuffizienz und Nebenniereninzidentalome

“…Gemäss der Richtlinie der European Society of Endocrinology soll bei homogenen adrenalen Inzidentalomen mit einer Grösse kleiner 4 cm und einer Dichte von ≤10 HU keine weitere Bildgebung gemacht werden [13,14]. Diese Empfehlung beruht v. a. darauf, dass solche Inzidentalome ein äußerst geringes Malignitätsrisiko haben und natürlich auch die Strahlenbelastung durch eine CT Untersuchung ein Malignom induzieren kann [15,18,19]. Bei Diagnose einer Zyste oder eines adrenalen Myelolipoms, welches durch sehr niedrige Dichtewerte (z.…”

Subclinical hypercortisolism: debatable or visible on the lightbox?

“…It is detected in a varying proportion of subjects, between 1 and 47 %, depending on the diverse criteria used to define it [5]. The finding of an adrenal mass undoubtedly raises concerns about the possibility of malignancy but adrenocortical cancer in this context is rare, especially when the size of the lesion is less than 4.0 cm, as is the case with most adrenal incidentalomas [6]. Thankfully, differentiation between benign and malignant adrenal lesions is visible with much accuracy with current imaging techniques.…”