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Management of the Clinically Inapparent Adrenal Mass
- Glenn D. Braunstein, MD; and
- for the National Institutes of Health State-of-the Science Adrenal Incidentaloma Panel
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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).
Glenn D. Braunstein, MD, for the National Institutes of Health State-of-the Science Adrenal Incidentaloma Panel
Cedars-Sinai Medical Center; Los Angeles, CA 90048
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
Article and Author Information
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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.
- Copyright ©2004 by the American College of Physicians
