Endocrine Abstracts (2008) 16 P107

Adrenal incidentalomas: which do we send for operation?

Ole Schmiedel & Aled Rees

Centre for Endocrine and Diabetes Sciences, Cardiff, UK.

Due to the increased availability and use of radiology, endocrinologists are referred patients with incidentally discovered, clinically silent adrenal masses with increased frequency. Controversies persist regarding their investigation and management. We present two cases focusing in particular on the role of radiology in the management algorithm.

A 43-year-old male underwent a CT urogram, which revealed an incidental 3×3×2 cm right adrenal mass. The patient did not have symptoms suggestive of mineralo- or glucocorticoid excess, but had been noted to have borderline hypertension. MRI scan confirmed a mass with high signal intensity on T2. Initial and repeated biochemistry over 18 months showed normal urinary metanephrines, negative investigations for Cushing’s syndrome and normal PRA/Aldosterone ratio. In May 2007, 2 years after his initial presentation, routine urine tests revealed elevated noradrenaline and normetadrenaline, in keeping with a diagnosis of phaeochromocytoma. MIBG confirmed increased activity within the right adrenal mass. This case illustrates the importance of continued biochemical testing for phaeochromocytoma when the radiology is suggestive.

A 71-year-old female was found to have a 4.5 cm right adrenal mass on abdominal CT. She had normal adrenal biochemistry on several occasions. Physical examination was unremarkable and her blood pressure was 140/80 mmHg. Based on the size of the tumour she underwent laparoscopic adrenalectomy. Histology showed a haemangioma of the adrenal medulla. There was no evidence of malignancy or an adrenal medullary or cortical endocrine cell tumour.

Careful review of abdominal radiology is important when investigating adrenal masses and may obviate the need for surgery in some patients, while prompting continued biochemical evaluation for endocrine disease in others. We propose that a greater emphasis should be placed on radiological review in current algorithms, but recognise that discharge or ongoing follow-up of hormonally silent radiologically stable lesions is still a dilemma.

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