II. Epidemiology
- Incidental Adrenal Mass found on up to 3-4% of Abdominal CTs or MRIs
- Incidental Adrenal Masses found in 20% of autopsies
III. Differential Diagnosis of Incidental Adrenal Mass
- Adrenal Adenoma (51%)
- Non-functioning adenoma
- Functioning adenoma
- Metastatic cancer (31%)
- Adrenal Carcinoma (1-4%)
- Adrenal Cyst (4%)
- Pheochromocytoma (4%)
- Adrenal Hyperplasia (2%)
- Lipoma (2%)
- Myelolipoma (2%)
IV. Labs
-
Pheochromocytoma Screening
- Consider plasma free metanephrines (in all patients)
- 24-hour Urine Metanephrines
- 24-hour Urine Vanillylmandelic Acid (VMA)
-
Cushing's Syndrome Screening
- Dexamethasone Suppression Test (in all patients)
- 24-hour Urinary Free Cortisol level
-
Hyperaldosteronism Screening (hypertensive patients)
- Serum Potassium
- Plasma Aldosterone to renin activity ratio
V. Imaging
-
CT Abdomen
- With IV contrast
- Low attenuation lesions (<10 Hounsfield Units) is more consistent with benign lesions
- With delayed-phase (to perform washout calculations)
- Adrenal carcinoma has a low washout
- With IV contrast
- MRI Abdomen with Chemical Shift
- Chemical shift confirms lipid-rich adenoma
- Indicated if CT with IV contrast contraindicated
- Fluorodeoxyglucose-positron emission testing (FDG-PET)
- Indicated for lesions not definitively characterized on CT or MRI
- High Test Sensitivity for malignancy
- Decreased Test Specificity for malignancy (False Positives possible)
VI. Evaluation: Reassuring findings suggestive of benign Adrenal Mass
- No history of other malignancy (lowers risk to 0.3% chance of cancer)
- Reassuring imaging findings suggestive of benign mass
- Lesions smaller than 4 cm with smooth borders
- Lipid-containing lesions
- CT with low attenuation (<10 Hounsfield Units) homogeneous mass
- MRI with signal loss on out-of-phase imaging
- Rapid-washout of IV iodinated contrast
VII. Indications: Follow-up Imaging
- Distinguish benign Lesions versus cancer
- Distinguish functioning versus non-functioning
VIII. Evaluation: Protocol
- Adrenal Mass on CT Scan <1 cm in greatest diameter (especially if fatty or cystic consistency)
- No further evaluation needed
- Adrenal Mass on CT Scan >4 cm in greatest diameter
- Evaluate endocrine labs above (especially to rule out Pheochromocytoma)
- Imaging
- Biopsy unless clearly benign (e.g. adrenal cyst, myelolipoma)
- Consult with surgery regarding possible excision
- Adrenal Mass 1-4 cm and lipid containing lesion on initial imaging (see above)
- Consider evaluating endocrine labs above (especially to rule out Pheochromocytoma)
- Repeat unenhanced CT Abdomen in 12 months to confirm no change
- Adrenal Mass 1-4 cm and not a lipid containing lesion
- Evaluate endocrine labs above (especially to rule out Pheochromocytoma)
- Perform CT Abdomen with IV contrast and delayed phase (or MRI as alternative)
- If CT or MRI non-diagnostic, consider FDG-PET
- Referral
- Endocrinology for functional adenomas
- General surgery for suspicious or non-diagnostic imaging
IX. References
- Cook (1996) Am J Med 101:88-94 [PubMed]
- Grumbach (2003) Ann Intern Med 138:424-9 [PubMed]
- Higgins (2001) Am Fam Physician 63:288-99 [PubMed]
- Hitzeman (2014) Am Fam Physician 90(11): 784-9 [PubMed]
- Yoh (2008) Ann Nucl Med 22(6): 513-9 [PubMed]
- Young (2007) N Engl J Med 356(6): 601-10 [PubMed]
- Willatt (2010) Am Fam Physician 81(11): 1361-6 [PubMed]
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Related Studies
Definition (MSHCZE) | Nádory nebo rakovina NADLEDVIN. |
Definition (NCI) | A benign or malignant (primary or metastatic) neoplasm affecting the adrenal glands. |
Definition (MSH) | Tumors or cancer of the ADRENAL GLANDS. |
Definition (CSP) | new abnormal adrenal gland tissue that grows by excessive cellular division and proliferation more rapidly than normal and continues to grow after the stimuli that initiated the new growth cease. |
Concepts | Neoplastic Process (T191) |
MSH | D000310 |
SnomedCT | 127021009 |
English | Neoplasm, Adrenal Gland, Neoplasms, Adrenal Gland, ADRENAL GLAND NEOPL, NEOPL ADRENAL GLAND, neoplasm of adrenal gland (diagnosis), neoplasm of adrenal gland, Adrenal neoplasm NOS, Adrenal neoplasms, Neoplasm adrenal, adrenal neoplasm, adrenal tumor, Adrenal Gland Neoplasms [Disease/Finding], Neoplasms, Adrenal, Neoplasm, Adrenal, Adrenal Neoplasm, adrenal gland neoplasms, adrenal gland tumor, adrenal gland tumours, adrenal neoplasms, adrenal tumours, tumor of adrenal gland, adrenal tumour, adrenal gland tumour, adrenal glands tumors, adrenal tumors, adrenal gland neoplasm, adrenal glands tumor, tumor adrenal gland, adrenal gland tumors, Adrenal glands--Tumors, Adrenal neoplasm, Adrenal tumor, Adrenal tumour, Tumor of adrenal gland, Tumour of adrenal gland, Neoplasm of adrenal gland (disorder), Neoplasm of adrenal gland, Adrenal Gland Neoplasm, Adrenal Gland Tumor, Adrenal Neoplasms, Adrenal Tumor, Neoplasm of Adrenal Gland, Neoplasm of the Adrenal Gland, Tumor of Adrenal Gland, Tumor of the Adrenal Gland, Adrenal Gland Neoplasms |
Italian | Tumore surrenale, Tumori della ghiandola surrenale, Tumore surrenale, NAS, Neoplasie della ghiandola surrenale |
Dutch | neoplasma bijnier, bijnierneoplasma NAO, bijnierneoplasmata, bijnierneoplasma, Bijnierneoplasma, Bijnierneoplasmata, Bijniertumor, Neoplasma, bijnier- |
French | Tumeur surrénalienne SAI, Tumeur surrénalienne, Tumeurs de la surrénale, Tumeurs surrénaliennes, Tumeurs de la glande surrénale, Tumeurs des surrénales |
German | Neubildung der Nebenniere NNB, Neubildung der Nebenniere, Neubildungen der Nebenniere, Nebennierentumoren |
Portuguese | Neoplasia supra-renal NE, Neoplasias das Glândulas Suprarrenais, Neoplasia supra-renal, Neoplasias da glândula supra-renal |
Spanish | Neoplasia de las glándulas suprarrenales NEOM, Neoplasia suprarrenal, neoplasia de la glándula suprarrenal (trastorno), neoplasia de la glándula suprarrenal, Neoplasia de las glándulas suprarrenales, Neoplasias de la glándula suprarrenal, Neoplasias de las Glándulas Suprarrenales |
Japanese | 副腎の新生物, 副腎新生物NOS, フクジンシンセイブツNOS, フクジンノシンセイブツ, フクジンシンセイブツ, 副腎新生物, 副腎腫瘍 |
Swedish | Binjuretumörer |
Finnish | Lisämunuaisten kasvaimet |
Russian | NADPOCHECHNIKOV NOVOOBRAZOVANIIA, НАДПОЧЕЧНИКОВ НОВООБРАЗОВАНИЯ |
Czech | Novotvar nadledvin NOS, Novotvar nadledvin, Adrenální novotvar, Nádory nadledvin, nadledviny - nádory, nádory nadledvin |
Croatian | NADBUBREŽNA ŽLIJEZDA, TUMORI |
Polish | Nowotwory nadnerczy |
Hungarian | Mellékvese neoplasia, Adrenalis daganat, Mellékvese neoplasia k.m.n., Mellékvese neoplasmák |
Norwegian | Binyresvulster, Binyretumorer, Binyreneoplasmer |
Ontology: Adrenal Cortical Adenoma (C0206667)
Definition (NCI_CDISC) | A benign neoplasm arising from any of the adrenal cortical layers. |
Definition (NCI) | A benign neoplasm that can arise from any of the adrenal cortical layers. It can be associated with the overproduction of glucocorticoids (Cushing's syndrome), androgenic or estrogenic steroids (adrenogenital syndrome), or mineralocorticoids (Conn's syndrome). (Sternberg Diagnostic Surgical Pathology, 3rd ed.) |
Definition (MSH) | A benign neoplasm of the ADRENAL CORTEX. It is characterized by a well-defined nodular lesion, usually less than 2.5 cm. Most adrenocortical adenomas are nonfunctional. The functional ones are yellow and contain LIPIDS. Depending on the cell type or cortical zone involved, they may produce ALDOSTERONE; HYDROCORTISONE; DEHYDROEPIANDROSTERONE; and/or ANDROSTENEDIONE. |
Concepts | Neoplastic Process (T191) |
MSH | D018246 |
ICD10 | M8370/0 |
SnomedCT | 18365006, 189646008, 134348000, 302826002, 255036008 |
English | Adenoma, Adrenocortical, Adenomas, Adrenal Cortical, Adenomas, Adrenocortical, Adrenal Cortical Adenomas, Adrenocortical Adenomas, Adrenal Cortical Adenoma, ADENOMA ADRENAL, Adenoma of Adrenal Gland, Adenoma of the Adrenal Gland, Adrenal Adenoma, Adrenal Gland Adenoma, Benign Adenoma of Adrenal Gland, Benign Adenoma of the Adrenal Gland, Benign Adrenal Adenoma, Benign Adrenal Gland Adenoma, Adrenocortical adenomas, Adrenal cortic. adenoma NOS, [M]Adrenal cortic. adenoma NOS, Adrenal cortical adenoma NOS, [M]Adrenal cortical adenoma NOS, Adrenal cortical adenoma-morph, Adrenal cortical adenoma - morphology, adrenal cortical adenoma, adrenal cortical adenoma (diagnosis), Adrenal cortical adenoma, no ICD-O subtype, Adenoma adrenal, Adrenocortical Adenoma [Disease/Finding], adenomas adrenal, adenoma adrenal, adrenocortical adenoma, adenoma adrenal cortical, adrenal adenoma, adenoma adrenal cortex, [M]Adrenal cortical adenoma NOS (morphologic abnormality), Adrenal cortical adenoma - morphology (morphologic abnormality), Adrenal cortical adenoma, no International Classification of Diseases for Oncology subtype (morphologic abnormality), Adrenal cortical adenoma, no ICD-O subtype (morphologic abnormality), Adrenal cortical adenoma, no International Classification of Diseases for Oncology subtype, CORTICAL CELL ADENOMA, ADRENAL GLAND ADENOMA, ADRENAL ADENOMA, ADRENAL CORTICAL ADENOMA, ADENOMA OF ADRENAL CORTEX, ADRENOCORTICAL ADENOMA, BENIGN ADENOMA OF ADRENAL GLAND, BENIGN ADENOMA OF THE ADRENAL GLAND, BENIGN ADRENAL GLAND ADENOMA, ADENOMA OF THE ADRENAL CORTEX, ADENOMA OF THE ADRENAL GLAND, ADENOMA, ADRENOCORTICAL , BENIGN, ADENOMA OF ADRENAL GLAND, BENIGN ADRENAL ADENOMA, Adrenal cortical adenoma, Adrenal adenoma, Adrenal adenoma (disorder), Adrenal cortical adenoma (disorder), Adrenal cortical adenoma morphology, adenoma; adrenal, adrenal; adenoma, Adrenal cortical adenoma, NOS, Adrenal cortical adenoma (morphologic abnormality), Adenoma, Adrenal Cortical, Adrenocortical Adenoma, Adenoma of Adrenal Cortex, Adenoma of the Adrenal Cortex, Adrenal Cortex Adenoma, Adenoma;adrenal |
Italian | Adenoma della ghiandola surrenale, Adenoma corticosurrenale |
French | Adénome surrénal, ADENOME SURRENAL, Adénome surrénalien, Adénome corticosurrénalien, Adénome cortico-surrénalien |
German | Nebennierenadenom, Adenom der Nebenniere, Adenom, Nebennierenrinden- |
Spanish | Adenoma de la Corteza Suprarrenal, Adenoma Corticosuprarrenal, adenoma de la corteza suprarrenal (anomalía morfológica), [M]adenoma corticosuprarrenal, SAI (anomalía morfológica), [M]adenoma corticosuprarrenal, SAI, [M]adenoma cortical suprarrenal, SAI, adenoma de corteza suprarrenal, no clasificado como subtipo en la Clasificación Internacional de Enfermedades para Oncología, adenoma de corteza suprarrenal, no clasificado como subtipo en la Clasificación Internacional de Enfermedades para Oncología (anomalía morfológica), adenoma de la corteza suprarrenal, no clasificado como subtipo en CIE-O, adenoma de la corteza suprarrenal, no clasificado como subtipo en CIE-O (anomalía morfológica), adenoma de corteza suprarrenal, adenoma de la corteza suprarrenal, adenoma corticosuprarrenal (trastorno), adenoma corticosuprarrenal, adenoma suprarrenal (trastorno), adenoma suprarrenal, Adenoma de glándulas suprarrenales |
Japanese | 副腎腺腫, フクジンセンシュ, コン病, 副腎皮質腺腫, Conn病, 腺腫-副腎皮質 |
Swedish | Binjurebarksadenom |
Czech | adenom kůry nadledviny, adenom adrenální kortikální, Adenom nadledvin, Adrenální adenom, adenom kůry nadledvin, adrenokortikální adenom |
Finnish | Lisämunuaisen kuorikerroksen adenooma |
Russian | ADENOMA ADRENOKORTIKAL'NAIA, ADRENOKORTIKAL'NAIA ADENOMA, ADENOMA ADRENOKORTIKOKLETOCHNAIA, АДЕНОМА АДРЕНОКОРТИКОКЛЕТОЧНАЯ, АДЕНОМА АДРЕНОКОРТИКАЛЬНАЯ, АДРЕНОКОРТИКАЛЬНАЯ АДЕНОМА |
Portuguese | ADENOMA SUPRARRENAL, Adenoma supra-renal, Adenoma do Córtex Supra-Renal, Adenoma Adrenocortical |
Polish | Gruczolak kory nadnerczy |
Hungarian | Mellékvese-adenoma, Jóindulatú mellékvese-mirigydaganat |
Norwegian | Binyrebarkadenom, Adrenokortikalt adenom |
Dutch | adenoom; bijnier, bijnier; adenoom, bijnieradenoom, Adenoom, adrenocorticaal, Adrenocorticaal adenoom, Bijnierschorsadenoom, Conn, ziekte van |
Ontology: Adrenal mass (C0342500)
Concepts | Disease or Syndrome (T047) |
SnomedCT | 237783006 |
Italian | Massa surrenale |
Japanese | 副腎腫瘤, フクジンシュリュウ |
Czech | Rezistence nadledviny |
English | Mass of adrenal gland, Adrenal mass (disorder), Mass of adrenal gland (finding), adrenal masses, mass adrenal, adrenal mass, Adrenal gland mass, Adrenal mass, Adrenal Mass, Mass;adrenal |
Spanish | masa suprarrenal (trastorno), masa adrenal, masa suprarrenal (hallazgo), masa suprarrenal, Masa suprarrenal |
Hungarian | Mellékvese térfoglaló folyamata |
Portuguese | Massa suprarrenal |
Dutch | bijnier gezwel |
French | Masse de la glande surrénale |
German | Raumforderung der Nebenniere |
Ontology: Adrenal incidentaloma (C2609247)
Concepts | Neoplastic Process (T191) |
MSH | C538238 |
Spanish | Incidentaloma adrenal |
Portuguese | Incidentaloma supra-renal |
Dutch | bijnierincidentaloom |
Italian | Incidentaloma surrenalico |
French | Incidentalome surrénalien |
German | Inzidentalom der Nebenniere |
Czech | Nadledvinová incidentaloma |
Japanese | 副腎偶発腫, フクジングウハツシュ |
English | Adrenal incidentaloma |
Hungarian | Mellékvese incidentaloma |