Adrenal incidentaloma and subclinical Cushings syndrome
The widespread use of abdominal CT/ MRI has resulted in a new and common diagnosis for the clinical endocrinologist the management of patients with adrenal incidentalomas. Defined as an adrenal mass discovered incidentally in the work-up or treatment of clinical conditions not related to suspicion of adrenal disease, incidentalomas cover a spectrum of underlying adrenal pathologies with a common pathway of discovery. Because of the risk of malignancy, they raise uncertainty, confusion and concern in doctors and patients alike and consume significant resource. We will define the scale of the problem, discuss diagnostic challenges as they relate to functionality of the tumours and ascertaining whether the lesions are benign or malignant. The natural history and suggested follow-up and treatment of patients based on published NIH clinical guidelines will be addressed; such guidelines perhaps over-inflate the real risk of malignancy and a more risk-averse approach to management is now required. Our new biomarker research based on analyzing the urinary steroid metabolome may improve the diagnosis and follow-up of such cases. One particular area of contention is the term sub-clinical Cushings reported in up to 15% of all cases; the suggestion being that this may account for underlying obesity, low BMD and cardiovascular morbidity. However diagnostic criteria vary considerably, have usually failed to comply with Endocrine Society guidelines with false positive results generating considerable uncertainty. In the absence of any test with 100% sensitivity and specificity, the issue is likely to be one of diagnosing mild Cushings syndrome where there is a limited evidence base that reversal of the condition significantly alters clinical features.
Declaration of interest: The author declares that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project.
Funding: This research did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.