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REPLY
Management of the Clinically Inapparent Adrenal Mass
Glenn D. Braunstein, MD, for the National Institutes of Health State-of-the Science Adrenal Incidentaloma Panel
2 March 2004 | Volume 140 Issue 5 | Pages 401-402
IN RESPONSE:
Dr. Copeland raises some good points. However, although several publications have appeared since our conference, high-quality data in sufficient numbers of patients are still lacking, thus the need for "additional research." Our specific responses are as follows.
1. The major issue to resolve with the various imaging techniques is the differentiation of benign adrenal adenomas from adrenal cortical carcinoma, since biochemical tests can distinguish an adrenal adenoma from a pheochromocytoma. As Dr. Copeland has noted, approximately half of the adrenal masses in patients with known cancer represent metastasis (1). It is in that group of patients that fine-needle aspiration of the adrenal mass is most useful in excluding metastatic disease if the findings on imaging are equivocal. In the study Dr. Copeland cites to advocate the routine use of delayed enhanced CT (2), 39 of the 40 malignant adrenal incidentalomas were metastatic lesions, while the remaining lesion was a malignant pheochromocytoma. None were adrenal cortical carcinomas. Until we have sufficient data that this procedure regularly distinguishes between primary adrenal adenomas and carcinomas, "additional research is needed."
2. Dr. Copeland is probably correct that a 6-cm lesion that "is smooth, homogeneous, low density (<2 HU), and nonfunctional ... is benign." However, there are not enough published data examining adenomas and carcinomas larger than 6 cm to warrant such a strong statement. As Dr. Copeland points out, autopsy series show that less than 2% of adrenal adenomas are greater than 4 cm in diameter and less than 0.03% are greater than 6 cm, while 92% of adrenal cortical carcinomas are greater than 6 cm (1). Thus, until more data are available, using size as a criterion to recommend surgery appears reasonable.
3. Several publications dealing with subclinical hypercorticolism and the adrenal incidentaloma were published after the State-of-the-Science Conference was held. These concern the association of adrenal incidentaloma with the metabolic syndrome (3), bone loss in men and women (4, 5), and cardiovascular risk (6). In the last study, 16 patients underwent surgery for an adrenal incidentaloma and showed a reduction in body mass index, blood pressure, and fibrinogen levels. In another report, 6 patients with subclinical hypercorticolism studied before and after surgery had improvements in systolic and diastolic blood pressure, a decrease in weight, and improvement in carbohydrate metabolism (7). Although these results are encouraging, the number of patients who have been studied before and after adrenalectomy for subclinical hypercorticolism is too small to make adrenalectomy a uniform recommendation at this time.
4. Until an imaging procedure is able to provide assurance that a lesion is not a pheochromocytoma, the potential danger attendant with missing this tumor is so high that most patients with an adrenal incidentaloma should have biochemical screening for pheochromocytoma. At the present time, plasma free metanephrines appear to provide the best overall receiver-operating curve characteristics balancing sensitivity and specificity for evaluating a patient with an adrenal mass for pheochromocytoma (8, 9).
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Author and Article Information
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From Cedars-Sinai Medical Center, Los Angeles, CA 90048.
Acknowledgments: The Panel acknowledges and thanks David C. Aron, MD; Stefan R. Bornstein, MD; Melvyn Korobkin, MD; and David E. Schteingart, MD, for their thoughtful and judicious contributions.
1. Copeland PM. The incidentally discovered adrenal mass: an update. The Endocrinologist. 1999;9:415-23.
2. Pena CS, Boland GW, Hahn PF, Lee MJ, Mueller PR. Characterization of indeterminate (lipid-poor) adrenal masses: use of washout characteristics at contrast-enhanced CT. Radiology. 2000;217:798-802. [PMID: 11110946].[Abstract/Free Full Text]
3. Terzolo M, Pia A, Ali A, Osella G, Reimondo G, Bovio S, et al. Adrenal incidentaloma: a new cause of the metabolic syndrome? J Clin Endocrinol Metab. 2002;87:998-1003. [PMID: 11889151].[Abstract/Free Full Text]
4. Chiodini I, Torlontano M, Carnevale V, Guglielmi G, Cammisa M, Trischitta V, et al. Bone loss rate in adrenal incidentalomas: a longitudinal study. J Clin Endocrinol Metab. 2001;86:5337-41. [PMID: 11701701].[Abstract/Free Full Text]
5. Chiodini I, Tauchmanova L, Torlontano M, Battista C, Guglielmi G, Cammisa M, et al. Bone involvement in eugonadal male patients with adrenal incidentaloma and subclinical hypercortisolism. J Clin Endocrinol Metab. 2002;87:5491-4. [PMID: 12466342].[Abstract/Free Full Text]
6. Tauchmanova L, Rossi R, Biondi B, Pulcrano M, Nuzzo V, Palmieri EA, et al. Patients with subclinical Cushing's syndrome due to adrenal adenoma have increased cardiovascular risk. J Clin Endocrinol Metab. 2002;87:4872-8. [PMID: 12414841].[Abstract/Free Full Text]
7. Bernini G, Moretti A, Iacconi P, Miccoli P, Nami R, Lucani B, et al. Anthropometric, haemodynamic, humoral and hormonal evaluation in patients with incidental adrenocortical adenomas before and after surgery. Eur J Endocrinol. 2003;148:213-9. [PMID: 12590640].[Abstract]
8. Lenders JW, Pacak K, Walther MM, Linehan WM, Mannelli M, Friberg P, et al. Biochemical diagnosis of pheochromocytoma: which test is best? JAMA. 2002;287:1427-34. [PMID: 11903030].[Abstract/Free Full Text]
9. Eisenhofer G. Editorial: biochemical diagnosis of pheochromocytoma—is it time to switch to plasma-free metanephrines? [Editorial] J Clin Endocrinol Metab. 2003;88:550-2. [PMID: 12574178].[Free Full Text]
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