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== Assessment of Bilateral Adrenal Masses == | ==Assessment of Bilateral Adrenal Masses== | ||
* [[Hormone|Hormonal]] assessments as mentioned in [[solitary]] [[adrenal incidentaloma]]. | *The differential diagnosis of bilateral adrenal masses include bilateral [[macronodular]] [[adrenal hyperplasia]] or [[Adenoma|adenomas]], [[congenital adrenal hyperplasia]], bilateral [[pheochromocytoma]], bilateral [[Adrenal tumor|adrenal]] [[hyperplasia]], [[Metastasis|metastases]], partial [[glucocorticoid]] [[Drug resistance|resistance]], [[Myelolipoma|myelolipomas]], [[hemorrhage]], and [[infection]]. | ||
* Measurement of the serum [[17-Hydroxyprogesterone|17-hydroxyprogesterone]] level to exclude [[congenital adrenal hyperplasia]]. | *[[Hormone|Hormonal]] assessments as mentioned in [[solitary]] [[adrenal incidentaloma]]. | ||
* If the imaging of bilateral adrenal masses shows [[hemorrhagic]] or [[Infiltrative and Metabolic Diseases Affecting the Liver|infiltrative]] features, testing for [[adrenal insufficiency]] should be performed. | *Measurement of the serum [[17-Hydroxyprogesterone|17-hydroxyprogesterone]] level to exclude [[congenital adrenal hyperplasia]]. | ||
*If the imaging of bilateral adrenal masses shows [[hemorrhagic]] or [[Infiltrative and Metabolic Diseases Affecting the Liver|infiltrative]] features, testing for [[adrenal insufficiency]] should be performed. | |||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammed Abdelwahed M.D[2]
Overview
There are no definitive diagnostic criteria for adrenal incidentaloma management but there are guidelines to diagnose and treat the mass according to Endocrine Society. Radiological evaluation including noncontrast CT attenuation value expressed in Hounsfield unit (HU) is the best tool to differentiate between benign and malignant adrenal masses. All patients should undergo hormonal evaluation for subclinical Cushing's syndrome and pheochromocytoma, and those with hypertension should also be evaluated for primary hyperaldosteronism.
Diagnostic Criteria
- There are no definitive diagnostic criteria for adrenal incidentaloma management but there are guidelines to diagnose and treat the mass according to Endocrine Society.[1]
- The guidelines recommend urgent assessment of adrenal mass in children, adolescents, pregnant females, and adults younger than 40 years of age because of a higher likelihood of malignancy.[2]
- The diagnostic approach in patients with adrenal incidentalomas depends on two important questions:
- Whether the lesion is malignant, or
- Whether it is hormonally active.
- Radiological evaluation including noncontrast CT attenuation value expressed in Hounsfield unit (HU) is the best tool to differentiate between benign and malignant adrenal masses.
- All adrenal tumors with suspicious radiological features, most functional tumors, and all tumors more than 4 cm in size with malignant radiological features should be removed surgically.
- All patients have to perform hormonal evaluation for subclinical Cushing's syndrome and pheochromocytoma, and those with hypertension should also be evaluated for primary hyperaldosteronism.
- Annual biochemical follow-up of most patients with an adrenal incidentaloma (particularly if the tumor is more than 3 cm in size) for up to 5 years is sufficient.
- Patients with adrenal masses less than 4 cm in size and a non-contrast attenuation value greater than 10 HU should have a repeat CT study in 3–6 months and then yearly for 2 years.
- Adrenal tumors with indeterminate radiological features that grow at least 0.8 cm over 3–12 months should be considered for surgical resection once other imaging and clinical characteristics have been taken into consideration.
| Adrenal mass | |||||||||||||||||||||||||||||||||||||||||||
| CT attenuation value< 10HU* | CT attenuation value> 10HU | ||||||||||||||||||||||||||||||||||||||||||
| Nonfunctional | Functional | < 4cm | > 4cm | ||||||||||||||||||||||||||||||||||||||||
| Yearly hormonal evlauation for up to 5 years | Surgical removal | Functional | Nonfunctional | Surgical removal | |||||||||||||||||||||||||||||||||||||||
| surgical removal | Calculate enhancement washout within 15 minutes | ||||||||||||||||||||||||||||||||||||||||||
| <60% | >60% | ||||||||||||||||||||||||||||||||||||||||||
| Surgical removal | No change in size in 12 months | > 0.8cm increase in size in 12 months | |||||||||||||||||||||||||||||||||||||||||
| Follow up CT image for two years | |||||||||||||||||||||||||||||||||||||||||||
HU;Hounsfield unit.
Assessment for Cancer
- An adrenal incidentaloma can be a primary malignant tumor that arises from the adrenal cortex (adrenocortical carcinoma) or medulla (pheochromocytoma), or can be metastatic tumor in rare occasions from lung cancer, renal cell carcinoma, gastrointestinal cancer, or melanoma. Imaging features and tumor size are essential for determining the probability of malignancy and also guiding treatment.
- Presence of irregular tumor margins, hemorrhage and necrosis, heterogeneity, increased vascularity, and calcification on imaging suggest cancer.
Imaging Features of Adrenal Incidentaloma[3]
Adrenocortical Adenoma
- Small size, less than 4 cm in diameter
- Smooth margin
- Homogenous consistency
- Usually unilateral but can be bilateral in 15% of cases
- Unenhanced CT attenuation: less than 10 HU
- Contrast-enhanced CT features: low attenuation, low vascularity, and fast washout
- MRI features: isointense in relation to liver on T2-weighted image and signal drop on chemical-shift imaging
- 18F-FDG PET-CT features: not avid, SUVmax less than 5, adrenal to spleen or adrenal to liver signal intensity ratio less than 1, and absent hemorrhage, necrosis and calcification
Pheochromocytoma
- Large size
- Smooth margin
- Heterogenous consistency
- Usually unilateral but can be bilateral
- Unenhanced CT attenuation: more than 10 HU
- Contrast-enhanced CT features: high attenuation, high vascularity, and slow washout
- MRI features: hyperintense in relation to liver on T2-weighted image and no signal drop on chemical-shift imaging
- 18F-FDG PET-CT features: avid, SUVmax more than 5, adrenal to spleen or adrenal to liver signal intensity ratio is equal or more than than 1-1.5, and hemorrhage, necrosis and calcification
Adrenocortical Carcinoma
- Large size, more than 6 cm
- Irregular margin
- Heterogenous consistency
- Usually unilateral
- Unenhanced CT attenuation: more than 10 HU
- Contrast-enhanced CT features: high attenuation, high vascularity, and slow washout
- MRI features: markedly hyperintense in relation to liver on T2-weighted image and no signal drop on chemical-shift imaging
- 18F-FDG PET-CT features: avid, SUVmax more than 5, adrenal to spleen or adrenal to liver signal intensity ratio is equal or more than than 1-1.5, and hemorrhage, necrosis and calcification
Metastasis
- Variable size
- Irregular margin
- Heterogenous consistency
- Usually unilateral but can be bilateral
- Unenhanced CT attenuation: more than 10 HU
- Contrast-enhanced CT features: high attenuation, high vascularity, and slow washout
- MRI features: hyperintense in relation to liver on T2-weighted image and no signal drop on chemical-shift imaging
- 18F-FDG PET-CT features: avid, SUVmax more than 5, adrenal to spleen or adrenal to liver signal intensity ratio is equal or more than than 1-1.5, and hemorrhage, necrosis and calcification in large tumors
Assessment of Bilateral Adrenal Masses
- The differential diagnosis of bilateral adrenal masses include bilateral macronodular adrenal hyperplasia or adenomas, congenital adrenal hyperplasia, bilateral pheochromocytoma, bilateral adrenal hyperplasia, metastases, partial glucocorticoid resistance, myelolipomas, hemorrhage, and infection.
- Hormonal assessments as mentioned in solitary adrenal incidentaloma.
- Measurement of the serum 17-hydroxyprogesterone level to exclude congenital adrenal hyperplasia.
- If the imaging of bilateral adrenal masses shows hemorrhagic or infiltrative features, testing for adrenal insufficiency should be performed.
References
- ↑ Fassnacht M, Arlt W, Bancos I, Dralle H, Newell-Price J, Sahdev A; et al. (2016). "Management of adrenal incidentalomas: European Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors". Eur J Endocrinol. 175 (2): G1–G34. doi:10.1530/EJE-16-0467. PMID 27390021.
- ↑ Sahdev A (2017). "Recommendations for the management of adrenal incidentalomas: what is pertinent for radiologists?". Br J Radiol. 90 (1072): 20160627. doi:10.1259/bjr.20160627. PMID 28181818.
- ↑ Kebebew E (2021). "Adrenal Incidentaloma". N Engl J Med. 384 (16): 1542–1551. doi:10.1056/NEJMcp2031112. PMID 33882207 Check
|pmid=value (help).