Evaluation and Management of Adrenal Masses

Sergio Gugisch Moreira, Jr, MD, and Julio M. Pow-Sang, MD


Cancer Control. 2002;9(4) 

In This Article

Treatment Options

All adrenal lesions that do not meet the criteria for nonfunctional benign disease require a carefully performed history and physical examination and biochemical workup to evaluate adrenal function. The majority of reports recommend that all functional adrenal tumors require treatment. Others, however, would agree that while aldosteronomas and pheochromocytomas, although clinically silent, should be surgically removed, the appropriate management of nonclinical hypercortisolism is still unclear. In these patients, surgical treatment would depend on several factors, including the degree of cortisol hypersecretion and concomitant hypertension, obesity, diabetes mellitus or impaired glucose tolerance and osteoporosis.

If the biochemical data are negative and the imaging characteristics are consistent with benign disease, the issue becomes whether the size of the adrenal lesion mandates removal or whether it can be followed safely with a non-operative intervention. As already noted, FNAB of an adrenal tumor cannot reliably distinguish between adrenal cortical carcinoma and a benign adrenal adenoma and should be reserved for patients with neoplasms elsewhere and when there is suspicion of metastatic disease. Because adrenocortical carcinomas are larger than benign masses (90% being more than 6 cm in diameter), mass size has been considered the most important predictor of the risk of malignancy, and there is general consensus that adrenal incidentalomas greater than 6 cm should be removed. Accordingly, most experts agree that any lesion larger than 5 cm should be removed unless classic characteristics are present that demonstrate unequivocal benign disease, such as a simple adrenal cyst or a myelolipoma. Most experts agree that lesions smaller than 4 cm can be followed with a serial imaging study. The ideal management of lesions between 4 and 5 cm remains unclear, and individual institutional variation exists. Some studies demonstrated that prevalence of adrenal nodules increases with age and suggested vascular rearrangements as a pathogenetic mechanism. Based on this concept, it is conceivable that the risk of malignancy of an adrenal mass may be lower in older than in younger patients and thus age, in addition to size, can be considered as a criterion for removing adrenal masses.[33] Therefore, adrenalectomy for a 3-cm adrenal mass would be advisable in a patient younger than 50 years of age, considering the low morbidity and mortality of surgery in young subjects, the risk of malignancy, the possibility of subclinical hyperfunction, and the elimination of the need for long-term follow-up.

The surgical approach consists of open or laparoscopic adrenalectomy. Several authors have compared both approaches retrospectively and concluded that laparoscopy is not inferior in terms of safety, efficacy, reliability, patient outcome, and side effects or complications. For patients with primary adrenal cancer, open surgery remains the technique of choice.[34] If an adrenal lesion is managed without surgery, a serial imaging study should be obtained, initially at 2 to 3 months from the diagnosis and then at 6 months. If the lesion has grown, surgical intervention is indicated. If the lesion remains stable, a second serial imaging study can be obtained at 6 months to 1 year. If the study is unchanged, it is unlikely that the lesion represents a malignant tumor, and additional imaging studies may not be required. Others would advise follow-up for the following 3 to 4 years, especially when factors such as an exclusive radiocholesterol uptake or subtle endocrine abnormalities at diagnosis indicate higher risk of progression of adrenal disease.


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