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Consider practicality, necessity when removing adrenal masses

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American Association of Clinical Endocrinologists 17th Annual Meeting & Clinical Congress

Adrenal incidentalomas are increasing in prevalence and continue to climb due to advancements of cross-sectional imaging, according to Geoffrey B. Thompson, MD, FACS, FACE.

“The root cause of this increase is our excellent, cross-sectional imaging modalities that are picking up these lesions,” Thompson, who is a professor of surgery at the Mayo Clinic, said today at the American Academy of Clinical Endocrinologists 17^th Annual Meeting & Clinical Congress.

Potential morbidities and possible mortalities associated with the excessive numbers of adrenalectomies, paired with an endless number of possible tests may leave physicians in a quandary.

Function

When deciding whether or not to remove functioning adrenocortical and medullary nodules, Thompson highlighted the importance of obtaining history and a physical exam to probe for signs and symptoms that would suggest primary aldosteronism, pheochromocytoma, clinical or sublicincal Cushing’s syndrome or virilizing/feminizing syndromes.

“We need to identify the basic screening tests for function. We need to make it simple so that we as endocrine surgeons can do it and our primary care colleagues can do it as well,” he said.

Adrenal tumors with suspicious radiographic phenotype, which Thompson classified as an often overlooked criteria in the decision making process, should be considered for adrenalectomy.

Tumor diameter and biopsy

Controversy concerning the maximal tumor diameter in relation to the risk for underlying primary adrenocortical malignancies makes decision making more difficult. A general consensus stated that adrenal incidentalomas greater than 6 cm in diameter have about a 25% risk of being an adrenocortical carcinoma, while those between 4 cm and 6 cm have a 6% risk and those under 4 cm have about a 2% risk, according to Thompson.

“One cannot differentiate an adrenal cortical carcinoma from adenoma by performing a biopsy on an adrenal mass,” he said.

Like those for tumor diameter, few guidelines exist concerning follow-up; however, Thompson suggests healthcare professionals consider practicality, cost-effectiveness and absolute necessity when deciding to remove an adrenal incidentaloma.

“In an ideal world, one would like to perform radiographic follow-up at three, six, 12 and 24 months, and functional follow-up yearly for four years,” said Thompson. – by Stacey L. Adams

For more information:

• Zeiger MA, Carty SE, McHenry CR, Thompson GB. Updates and controversies in the surgical management of well-differentiated thyroid cancer, primary hyperparathyroidism, and adrenal neoplasms. Presented at: the American Association of Clinical Endocrinologists 17^th Annual Meeting & Clinical Congress; May 14-18, 2008; Orlando, Fla.